English - French Health System

Organisation
and
health system
in France
www.gipspsi.org
INTRODUCTION
The French health system
ll international studies rank the French healthcare system among the top systems in the world in terms of results. Although its origins go back to the Middle Ages, the modern French health system is inextricably linked to the social security system, and more specifically to the health insurance system. In reality, the healthcare system began to develop in 1945 and has expanded more rapidly since the 1960s, thanks to the enactment of a number of major reforms. Today, this very close bond between the health system and the welfare system enables almost everyone in France to enjoy access to quality local healthcare services. The French system is also one of the most generous in terms of coverage, which makes it a model that is often envied, although its cost amounts to a large share of gross domestic product (11%). One of the main characteristics of the French health system is the fact that it has expanded while preserving the freedom of choice enjoyed by patients and the different parties involved. As a result, healthcare facilities include public hospitals and private clinics. Patients are free to choose their general practitioner and their healthcare facility. Likewise, private doctors are free to set up their practice wherever they want, are paid on a per appointment basis and are free to prescribe as they see fit. The relationship between the health insurance system and healthcare professionals is regulated by conventions. The pragmatism of the French system - which combines social security coverage with a liberal approach - has enabled it to adapt to all the changes that have occurred over the past few decades and to acquire a high level of expertise. Although it does not claim to be exhaustive, the present brochure provides an overview of this unique system, which is currently bracing itself to meet new challenges.
The following contributed to this work: the French Ministry of Health (DGS, DSS, DGOS and DAEI), the CNAMTS, the RSI, the MSA, the FHF, the Mutualit Franaise (French Mutual Benefit Funds Association), the EHESP and the French Ministry of Foreign Affairs (Department of World Affairs). September 2010
CHAPTER 1:
History of the healthcare system

The French healthcare system, as it is structured today, is the product of a lengthy evolution. Although its history is connected to social policies aimed at covering the risk of illness, the French health system remains closely linked to the development of hospitals and of the medical sector.
CHAPTER 1: History of the healthcare system

I - The emergence of healthcare organisations

Places where charity was dispensed to the destitute and the sick
In the West, hospital-type organisations only really appeared with the spread of Christianity. In France, hospices were found along the major pilgrimage trails from the mid-8th century onwards: in addition to welcoming travellers, these sanctuaries regularly provided shelter to the poor and sick in the area. The number of foundations grew rapidly between the 6th and the 8th centuries: in Arles, Lyons, Reims, etc. Known as Houses or Hostels of God, these institutions were run by the Church during the Middle Ages. When it was founded by Bishop Saint Landry in 651, the Paris Hotel-Dieu was the largest in the kingdom. From the 12th century onwards, the hospitals were exclusively run by nursing monastic orders, like the Antonines, the hospital brothers of Saint Anthony. At a time when medicine had not really developed, these institutions were intended to provide shelter for destitute patients and so keep individuals who were dying or marginalised away from the rest of the population. Hospitals retained this social function for a long time before becoming places where patients were cared for.
The gradual secularisation of hospitals

Between the 12th and 15th centuries, the Hotels-Dieu (Hostels of God) were supplemented by foundations built by great noblemen or by the King. At the end of the Middle Ages, the power of the King replaced that of the Church in administering the hospitals, as well as in creating institutions to combat beggary: la Salptrire, Bictre, Sainte-Anne, and Saint-Louis. As well as locking up patients during epidemics, these general hospitals fulfilled a public order role by interning beggars and other troublemakers. When workhouses were opened in 1767, the hospitals assumed other roles, including the provision of healthcare. Despite their very indifferent hygiene, the HotelsDieu remained the main medical organisations. In the early 18th century, military hospitals attached to strongholds became models for civilian institutions, which were becoming increasingly specialised. At the same time as the hospital network was becoming more secular, and as a reaction to that trend, the number of private and religious foundations increased sharply, as did the works they performed. A multitude of organisations flourished: hospitals, hostels, charitable houses, asylums, etc. Nursing care in these institutions was provided by brotherhoods or sisterhoods like the Daughters of Charity of Saint Vincent de Paul.

The State as protector

The French Revolution of 1789 was the cause of many changes. Most of the institutions of the French Ancien Rgime were abolished, and nursing orders were prohibited. Treatment institutions were nationalised: hospitals and hospices were administered by municipalities, while lunatic asylums were granted departmental status. Hospitals gradually became medical training centres and contributed to the emergence of clinical medicine. These changes enabled a standardisation of teaching conditions and of the practice of medicine throughout the country. Although the Revolution crystallised the need for reform and highlighted the desire to make health an affair of State, certain ventures were the result of older ways of thinking. For example, the Royal Medical Societys Remedies Commission recommended a collective approach to public hygiene issues. Moreover, even if the existing system was disparaged and partly dismantled, many reforms remained dead in the water. In fact, religious orders retained their dominance over healthcare facilities. The first municipal emergency treatment institutions, which were known as welfare offices, were only created in 1796. In large towns, they relied on dispensaries in order to provide free healthcare to the poorest. In the early 19th century, the General Council of Paris Hospitals and Hospices introduced the first type of central administration for healthcare and charitable organisations. The Council was replaced by the French Welfare Service in 1849.
The Hygienic State

From the 19th century onwards, medical advances changed the approach to diseases and introduced new measures for combating epidemics. The issue of hygiene became a collective concern. Henceforth, the State was responsible for ensuring that public health was protected. It therefore established the first ground rules, like medical insurance policy payments, and put in place important legislation, including the Law of February 15th 1902. That law defines the first action framework for municipalities and departments. The founding of the Ministry of Health in 1920 and the enactment of a Public Health Code under the Vichy Government confirmed the States role in this area.
Socialisation of the demand for healthcare

In the mid-19th century, the growth of paid employment and industrialisation gradually led governments to provide welfare payments in the event of illness. In 1893, the Third Republic guaranteed access to healthcare for the poorest members of society through the

law on free medical assistance. It also authorised the re-appearance of mutual assistance companies, which had been dissolved by the Le Chapelier law, a law that banned guilds. In 1898, the law on accidents in the workplace created insurance coverage for professional risk. Faced with the social initiatives introduced by Bismarck and pressure from workers movements, France extended health insurance coverage to all employees through the laws of 1928 and 1930 on compulsory welfare insurance.
II - A socially responsible healthcare system

The advent of liberal medicine
On the eve of the French Revolution, the medical profession was divided into two classes: surgeons and apothecaries on one side, and doctors of medicine on the other. However, resorting to self-medication, to charlatans or other travelling healers remained the norm, especially in the countryside. From 1803 onwards, only holders of an official diploma were authorised to practice, and the profession divided into two groups: doctors of medicine and health officers. The difference in their status was based on the length of their studies and the place where they practised: doctors were more highly qualified and practiced in town, while health officers followed shorter courses of study and practised in rural areas. This two-speed medicine, which was a source of competition and conflict, disappeared when both classes of practitioners were merged and a professional status was created in 1892. The medical body thus enforced its monopoly on the healthcare market. Faced with the emergence of free medical assistance policies and attempts to regulate their practice, doctors organised themselves, in order to safeguard their independence and their material interests: freedom to refuse to care for the destitute, free choice of doctor, payment per procedure rather than on a flat-fee basis. The doctors unions, who had been opposed to compulsory membership of the collective health insurance system since the late 19th century, came together within the French Federation of Medical Unions, or CSMF, and adopted the Private Medicine Charter in 1927. This document was more a statement of the principles of private doctors collective identity than a defence of their professional interests. The movement was also reflected in the founding of the French Association of Doctors in 1940, which established the rules for the profession. Due to its strong desire for independence, the medical profession managed to safeguard its privileges from the public authorities and social security bodies established straight after the Second World War.

A universal healthcare system

After 1945, universal healthcare was the order of the day in Europe. In France, strengthening the welfare system resulted in an increase in the number of beneficiaries and of the risks covered. In October 1945, the introduction of the general social security scheme included a health insurance branch for all employees in the private commercial and industrial sectors. Originally, that branch was meant to become the single model for all professions, but standardisation never happened. Nowadays, the French healthcare system includes three separate major compulsory health insurance schemes and several schemes known as special schemes1. Since 1945, there has been a succession of laws aimed at extending the welfare system to cover the maximum number of people, especially for the benefit of the poorest members of society through the introduction of Universal Healthcare Coverage in 1999.
Public Hospital and Sanitation Planning Department

In 1958, the Debr Reform created University Teaching Hospitals (Centres HospitaloUniversitaires, or CHU) and introduced the ranking of public hospitals. Full-time hospital doctors are experts in three areas, since they practice, teach and carry out research at the same time: they are described as University Professors-cum-Hospital Consultants (Professeur des Universits-Praticien Hospitalier, or PU-PH). They benefit from being on the staff of the hospital and the university and the hospital then establishes itself as a healthcare, research and teaching centre. These consultants can also engage in private practice at the same time. The Law of December 31st 1970 created a Public Hospital Service (Service Public Hospitalier, or SPH), which is based on drawing up a public health map divided into sectors and on co-ordination between public and private institutions. The aim of this planning attempt is to make the French hospital pool more consistent in terms of resources, specialisation and geographic cover. As a result, thanks to improved co-ordination between high-tech services and the number of beds, co-operation between hospitals enables savings to be made, especially for treatments that require most heavy equipment.
1 See health insurance chapter

Regional management of the healthcare system

The Law of 31st July 1991 was a turning point in French healthcare planning: since 1996, the healthcare system has been managed and organised at the regional level under the governance of Regional Hospital Agencies (AHS) (Agences Rgionales de lHospitalisation, or ARH). The Regional Public Health Organisation Programme (Schma Rgional dOrganisation Sanitaire, or SROS) is the final addition to the public health map and is aimed at assessing and updating regional healthcare requirements. Within the framework of the Hpital 2007 (Hospital 2007) plan, the organisation and planning of the healthcare service will undergo significant changes. The SROS has become the sole regional planning tool and the public health map has been abolished in favour of a new treatment organisation regulatory framework, known as the health region. These regions are redefined by each regional hospital agency according to specific public health, demographic and political factors. The Regional Hospital Agencies (AHS), which are now responsible for granting authorisations, actually manage the healthcare plans within their region. Finally, the aim of the Law of July 21st 2008 on hospital reform and concerning patients, health and the regions is to modernise the entire health system by focusing on four sectors: hospitals, the distribution of doctors and access to healthcare in towns, public health and preventive measures, and the regional co-ordination of legal systems with the founding of Regional Health Agencies (ARS) (Agences Rgionales de Sant, or ARS), which have replaced Regional Hospital Agencies (AHS) from 2010 onwards. Regional Health Agencies (ARS) are bringing the management of all health services together within the same agency and are extending their capabilities to the medico-welfare sector.
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CHAPTER 2:
Principles, general organisation and management

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CHAPTER 2: Principles, general organisation and management

The uniqueness of the French hospital system

In France, the historical development of the healthcare system resulted in a type of hybrid organisation based on several fundamental principles. The French system, which was inspired by the Bismarckian corporatist model, allows for welfare schemes that are linked to a professional activity. It also draws on Beveridges universal concept, which defends the idea of an individual right to protection, and aims to cover health risks for the population as a whole. Even though it aims to guarantee the same rights to individuals covered by social security, the current French healthcare system is not consistent. On the one hand, it includes three separate major health insurance schemes, which guarantee coverage for salaried employees as well as for unsalaried farm workers or independent workers, whether they are active or retired, and their dependents. On the other, it includes several schemes that are known as special, which are linked to a limited number of professions. In accordance with the representation principle, each scheme is managed by representatives of the population group that it insures. Finally, unemployed individuals are also covered, either because they benefit from assistance and welfare measures intended for the most deprived members of the population, or because they depend on the general insurance scheme, in the absence of any other French health coverage. The generalisation of health insurance, including for the benefit of deprived population groups, guarantees access to healthcare for the great majority of people. Moreover, the overall operation of the healthcare system depends on the State and different competent entities sharing skills. Although these organisations enjoy a certain operational independence, the system remains strictly regulated and controlled by the State.
I - The principles of a pluralistic system

Freedom of choice within the healthcare system
The French healthcare system is based on pluralistic treatment provision. Indeed, the system is based on the co-existence of public and private practitioners, even in the hospital sector, which consists of three types of institution: public hospitals, private not-for-profit hospitals and for-profit institutions, which are usually called clinics in France. The plurality of the system is also reflected in the guaranteed status of the private healthcare professions and the existence of a public hospital service.
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The system also respects the patients freedom of choice. In accordance with the principle of the free choice of doctor, every individual is in a position to choose his general practitioner, or to approach a specialist directly, to choose his healthcare institution or the medical service that best meets his requirements and preferences, both in the public and private sectors. However, in order to improve the monitoring of patients and the co-ordination of treatment, the 2004 health insurance reform introduced the notion of a coordinated treatment path for patients and the requirement for them to choose a primary general practioner, or attending doctor. Except for certain medical specialisations, patients are encouraged to consult their attending doctor first before going to see a specialist. The patient is free to go directly to the specialist, but his health insurance provider will then reimburse him at a lower rate than the usual rate. In 2009, 85% of French people had chosen an attending doctor. The 2004 reform also allows for the creation of an electronic personal medical file. The file will aggregate all the information on the patients health and enable different healthcare providers to access his medical history.
Reimbursement of healthcare expenses

In France, the reimbursement of individual healthcare expenses involves a public portion, which is funded by the compulsory health insurance funds and a second portion, which is covered by mutual benefit funds, welfare bodies and private insurance companies. All these organisations cover the same population groups and the same medical services, in order to guarantee optimal coverage. In France, the public health insurance system funds around 75% of healthcare expenditure. Certain medical interventions, such as those relating to childbirth, to long and costly illnesses or accidents in the workplace, are reimbursed in full. Completely free provision of these treatments is based on the direct payment principle: the patient does not pay anything and the health insurance scheme refunds the healthcare professional. Patients also contribute to the funding of their healthcare. First, because part of that healthcare is still only partially covered. The co-payment portion corresponds to the part that is not reimbursed and for which the patient is responsible. This system implies a financial contribution from the patient and is primarily aimed at making him take more responsibility for his healthcare expenses. The patient may, however, cover all or part of the co-payment by taking out a top-up health insurance
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policy on an individual basis, or more usually through a work-related top-up healthcare policy. In the same spirit of making patients take responsibility, the latter must make a flat-rate contribution of one euro for medical procedures1, and pay a daily flat-rate charge when they are in hospital, except for stays that are known as long-term stays.
The French Carte Vitale health insurance card

Every policyholder has a confidential card that corresponds to his social security registration number: the Carte Vitale. The card, which is equipped with a secure electronic chip, holds all the patients health insurance entitlements. That information can only be accessed by certain healthcare professionals. By regularly updating their Carte Vitale, policyholders update their rights and so benefit from optimum patient care. When they present their card at an appointment or when buying drugs in a chemists, they are guaranteed a refund within five days. The card simplifies and speeds up the process for patients, like sending a treatment receipt to their insurer by mail. In addition to triggering immediate repayment, the card allows the patient not to pay for the portion covered by the health insurer as a third-party payment in advance, or for the amount payable by the top-up health insurance company in some cases. The card is accepted by all treatment institutions, chemists and by private doctors.
Socialisation of health insurance

The funding of the French healthcare system is mostly pooled. Compulsory health insurance bodies are financed first and foremost by national insurance contributions based on salaries and by a levy on all sources of income - including financial income -, which is known as the General Social Security Contribution (Contribution Sociale Gnralise, or CSG). This funding method is in accordance with the principle of dividing contributions equally: the insurance body receives a double contribution, from the employee and the employer. It is also based on the principle of social responsibility and redistribution of wealth: everyone pays according to their income, and not according to their risk profile.
1 See Chapter 8 on health insurance, p 71
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II - Organisation and regulation of the French healthcare system

In France, the healthcare system is still mostly managed by the public authorities. Even if different bodies and administrative organisations are involved in managing the system, the State still guarantees the consistency of patient care and redistribution mechanisms. Public healthcare capabilities and the regulation of the treatment provision are subdivided between three institutional and regional levels: the State, the health insurance company2 and the local area.
The State
As the guarantor of improvements in the populations state of health, the State plays a fundamental role in planning and organising the range of public health goods and services. It is directly involved in funding and providing treatment. In order to respond to the populations expectations and requirements, it favours consistent coverage of the French territory and efficient interaction between the various players in the sector. The State assumes a wide range of responsibilities, either directly or via specialist organisations3: Those responsibilities include: defining general public health policies for prevention, health monitoring and combating diseases and addiction (tobacco, drugs, alcohol, etc.); organising and overseeing the entire healthcare system and healthcare bodies; training healthcare professionals and accrediting treatment institutions; providing financial support for the investments made by treatment institutions and setting their operational budgets; overseeing and acting as a guardian for (compulsory and top-up) health insurance bodies.
2 See chapter on health insurance, p 71 3 See chapter VII on Healthcare Agencies, p 63
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In order to make sure that the system is functioning properly and that the care provided is of the highest quality, the State also performs checks at several levels: funding and allocation of resources, the pharmaceutical industry, compliance with quality standards, doctor-patient relationships, etc. The main action takes place at two levels, at the level of the French Parliament and at the level of the Government.
The role of Parliament

Every year, Parliament determines the forecast budget and the operating conditions for the social security system through a vote on the Social Security Funding Bill (Loi de Financement de la Scurit Sociale, or LFSS). That bill sets out the National Health Insurance Spending Target (Objectif National de Dpenses dAssurance Maladie, or ONDAM), major healthcare guidelines and the methods for implementing the new operating and regulation provisions.
The role of the Government

At the national level, two main ministries are involved in managing the treatment provision: the French Ministry of Labour and Social Relations and the Health Ministry. They are involved via four administrative departments: The General Health Department (DGS), which is responsible for public health policies, and for public health oversight and safety; The General Department of Treatment Provision (Direction Gnrale de lOffre de Soins, or DGOS), which is responsible for managing the systems resources and means; The Social Security Department, which is responsible for funding, acts as a guardian for social security bodies; In 2010, the General Department for Social Cohesion (Direction Gnrale de la Cohsion Sociale, or DGCS) now takes care of specific public health and social issues, such as disability, the elderly and vulnerable population groups. The Ministry of Health has jurisdiction in financial and regulatory matters. It allocates the forecast expenditure and sets the rates for healthcare services. In addition to drawing up national programmes in priority public health areas, the Ministry defines a series of operating standards, like the annual number of medical students (numerus clausus) or the equipment level for hospitals for items like beds and other expensive equipment.
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Meanwhile, the Budget Ministry is involved in all decisions and control procedures relating to controlling costs in the healthcare system. Finally, the National Health Authority4 (Haute Autorit de Sant, or HAS) performs assignments linked to the quality of the services provided. In addition to overseeing improvements in the quality of healthcare services and the control of healthcare expenditure, the Authority also promotes consultation between players in the healthcare system and so contributes to promoting best practice for professionals and patients.
A trend towards regionalisation...

The way management of the system is organised has tended to become less centralised over the past few years. More responsibility is now assigned at the area level and more especially at the regional level. Before the enactment of the Law of July 21st 2009 on hospital reform and concerning patients, healthcare and the regions in 2010, Regional Hospital Agencies (AHS) (ARH), Departmental Public Health and Welfare Departments (Directions Dpartementales des Affaires Sanitaires et Sociales, or DDASS) and Regional Health and Welfare Departments (Directions Rgionales des Affaires Sanitaires et Sociales, or DRASS), provided the institutional backbone for implementing social, healthcare and medico-social policies, as well as the efficient management of treatment at the local level.
4 For further detail on the role of the National Health Authority, see chapter 7 on healthcare agencies, p 63
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FOCUS: From Regional Hospital Agencies (AHS) to Regional Health Agencies (ARS)
Since 2010, when Regional Health Agencies (ARS) replaced Regional Hospital Agencies (AHS), a new structure has emerged. As the governing bodies responsible for managing the healthcare system in the regions, Regional Health Agencies (ARS) guarantee an organisational structure that is more integrated into the local area, with more efficient support for healthcare professionals and a more detailed assessment of patient requirements. There are 26 Regional Health Agencies (ARS): one per region in metropolitan France and four in the French Overseas Territories. These agencies bring together all the players in the healthcare system and all the medico-social players in a given region, in order to increase the effectiveness of treatment provision. The aim is threefold: ensuring better co-ordination of treatments, making sure that resources are managed in a more consistent manner and guaranteeing a more balanced access for the population as a whole. The Regional Health Agencies (ARS) field of expertise is broader than that of the Regional Hospital Agencies (AHS), which managed public and private hospital admissions (regional public health organisation programmes, the regional hospital treatment policy, which primarily specified treatment institutions level of resources, and multi-year target and resources contracts). In addition to extending its coverage to private medicine and the medico-welfare sector, the reform grants Regional Health Agencies (ARS) prerogatives on public health issues and assigns them the task of adapting healthcare and prevention policies to their regional context. At the same time - within the framework of the General Public Policy Review (Rvision Gnrale des Politiques Publiques, or RGPP) - the Regional Public Health and Welfare Departments (DRASS) were absorbed into the Regional Health Agencies (ARS), while the Departmental Public Health and Welfare Departments (DDASS) were combined with other local social authorities and became Departmental Social Cohesion Departments (Directions Dpartementales de la Cohsion Sociale, or DDCS) or Departmental Departments for Social Cohesion and Protection of the Population (Directions Dpartementales de la Cohsion Sociale et de la Protection des Populations, or DDCSPP).
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CHAPTER 3:
Out-patient care and healthcare professionals
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CHAPTER 3: Out-patient care and healthcare professionals

The French healthcare system relies both on specialist organisations and a range of expertise, including healthcare professionals and professionals from the paramedical and welfare sector. In aggregate, the medical professions represent around 8% of the French working population, or 1.8 million people. The healthcare profession is divided into several categories, depending on the medical specialisation and the level of training. The healthcare sector also calls upon skills used in the medico-social and welfare sector. We therefore make a distinction between medical healthcare professions and paramedical healthcare professions and similar, which also contribute to the production of healthcare services. The first category includes doctors, dental surgeons, pharmacists and midwives. These professions, which are regulated by the CSP, operate within a strict legal and statutory framework, in order to guarantee the quality and safety of the medical services delivered. The framework also aims to guarantee uniform access to treatment throughout the country. Healthcare professionals practice on a private basis or as employees of a treatment institution or other organisations that rely on their expertise (social security, medical care in the workplace or in schools, etc.)
I - Medical professions
These professions are governed by the French Public Health Code (CSP) and require a State diploma that is obtained after a lengthy period of study (10 years on average). The regulations require registration on a prefectural list, as well as the delivery of a professional licence. Numbers in the medical profession are restricted by a numerus clausus, in order to limit the number of students registering for the first stage of a medical degree. In addition, each specialisation is attached to a professional chamber that is responsible for compliance with the code of ethics (registered under the CSP) and for regulating relationships between professionals. A breach of the regulatory framework may result in criminal sanctions, and
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non-compliance with the professional ethics specified by the Code may result in disciplinary proceedings up to and including being permanently struck off.
Distribution of doctors by speciality and mode of practice (throughout France)
Pathological anatomy and cytology Anasthaesia-resuscitation Medical biology Cardiology and vascular diseases Surgery of the face and neck General surgery Paediatric surgery Maxillofacial surgery Orthopaedic and trauma surgery ERCP Thoracic and cardiovascular surgery Urological surgery Vascular surgery Visceral and digestive surgery Dermatology and venereology Endocrinology and metabolism Gastroenterology and hepatology Medical genetics Geriatrics Medical gynaecology Medical and obstetric gynaecology Obstetrics and gynaecology Haematology Occupational medicine General medicine Internal medicine Nuclear medicine Physical and rehabilitational medicine Nephrology Neuropsychiatry Neurosurgery Neurology Oncohaematology Medical oncology Ophthalmology ENT Paediatrics Pneumology Psychiatry Children and adolescent psychiatry Radiodiagnostics and medical imaging Radiodiagnostics and radiotherapy Radiotherapy and onco-radiotherapy Intensive care medicine Medical research Rheumatology Public health and social medicine General medical speciality Stomatology Independent 574 2976 1034 2527 1 1051 24 104 1199 436 85 457 229 266 2402 476 1247 4 35 1134 1018 1139 9 27 39321 210 155 380 208 71 81 434 4 109 3250 1356 1745 652 3359 327 3941 60 221 4 0 1198 17 19787 618 Mixed 151 427 128 1588 2 686 43 44 609 209 54 198 106 115 800 292 784 4 31 456 595 834 6 17 5229 246 77 169 139 45 57 368 2 47 1399 871 917 464 2068 227 1245 12 119 2 0 580 9 2037 304 Salaried 738 6280 1439 1866 2 1708 162 41 796 77 162 208 132 327 578 752 1272 191 725 184 329 1443 259 5849 29657 1840 316 1212 866 62 266 1116 11 462 697 574 3882 1445 6187 621 2082 14 329 120 11 694 1521 1613 112 Miscellaneous 2 6 29 26 0 9 0 0 2 0 0 0 0 0 13 11 11 0 0 2 1 0 3 4 957 17 1 3 5 2 0 9 0 7 8 3 28 9 14 1 3 0 0 0 3 19 34 5 1 None 0 3 0 1 0 6 1 0 1 0 0 0 0 0 2 1 0 0 0 0 0 1 0 0 40 3 0 1 0 0 1 0 0 0 0 1 3 1 3 3 5 0 0 0 0 3 1 0 1 Total 2009 1465 9692 2630 6008 5 3460 230 189 2607 722 301 863 467 708 3795 1532 3314 199 791 1776 1943 3417 277 5897 75204 2316 549 1765 1218 180 405 1927 17 625 5354 2805 6575 2571 11631 1179 7276 86 669 126 14 2494 1582 23442 1036
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Table extracted from the French 2009 medical demographics atlas, French Medical Council

A - Practitioners
General practitioners and specialists A distinction is made between doctors of medicine who are in general practice or who specialise, on the one hand, and general or specialist surgeons, on the other. As at January 1st 2009, 216,0171 practising doctors were registered on the Roll of the French Medical Association: 209,143 in metropolitan France, 6,060 in the French Overseas Departments and Territories, and 814 who were resident abroad. The number of doctors has been increasing at an average rate of 2% per year since the 1990s. Members of the association include 9,631 European and non-European doctors, who are usually established in the Ile-de-France or border regions. General practice, which is also known as out-patient care, includes generalists and specialists. The latter represent around 60% of working practitioners and provide a major part of the overall treatment provision. They practice in surgeries, alone or as a group, and are paid per procedure within the framework of agreements drawn up between the medical trade union organisations and the national health insurance fund. Private Special Interest Practitioners (Mdecins Libraux Mode dExercice Particulier or MEPs) provide complementary services, like acupuncture or homeopathy, or practice in several areas. There are around 6,700 such practitioners in France and they are mainly concentrated in the Paris area. Among the 95,000 salaried doctors, almost 90% work in the public sector. Full or part-time hospital practitioners are public employees recruited through national examinations, although they can also be hired on a contractual basis. Public hospitals allow their doctors to work on a part-private basis within the actual institution: this is the case for a third of them. In teaching hospitals, practitioners have a dual status in order to fulfil their teaching and research mandates. There were around 4,400 doctors in clinics in the private sector and around 10,900 practitioners in private not-for-profit institutions. Doctors under private contract are paid in accordance with the collective agreements applicable in each institution.
1 - 2009 French Medical Demography Atlas, (French Medical Council)
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Private medical practice As compulsory health insurance schemes began developing in the early 20th century, doctors organised themselves in order to defend the independence of their profession and adopted the Private Medical Charter in 1927. They remained attached to their independent status and objected to interference from the public authorities and the fact that they were under the guardianship of the health insurance system. The Charter is based on a set of principles, which guarantee both the economic interests of the profession and the freedom of patients when choosing the treatment provision. The practitioner is free to set up where he chooses; Absolute respect for professional secrecy; The patients free choice of doctor; Freedom of prescription; Fees to be agreed freely between the doctor and the patient; Payment per procedure and direct payment by the patient (no direct payment for general healthcare); Ethical and professional checks to be carried out by professional bodies and not by health insurance funds; Medical unions to be represented within health insurance funds. These principles are still relevant despite successive reforms aimed at creating a framework for private medicine. The changes relate mainly to the patients freedom to choose, with the introduction of an attending doctor, and to the amount of practitioners fees, with the introduction of statutory rates. In contrast, payment per procedure remains a fundamental principle, as it contributes to the quality of treatment. Indeed, if the medical service is inappropriate or not very satisfactory, the patient is free to choose another attending doctor or to go and consult another practitioner. However, there is no total freedom of prescription in actual fact. In addition to complying with the limits imposed by law, a prescription complies with the professional code of ethics, which calls upon the doctors moral duty of assistance and requires him to prescribe only what is necessary for the quality, effectiveness and safety of the treatment. For economic reasons, doctors are encouraged to favour generic drugs. Every year, doctors receive their personal prescription profile, which provides feedback on practices and comparisons. This document covers all their prescriptions (generic drugs, medical leaves of absence, etc.) and ranks them according to a departmental average. If a doctor appears to be abnormally far from the average, a
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consultant doctor from the Primary Health Insurance Fund (Caisse Primaire dAssurance Maladie, or CPAM) may examine his practices in greater detail. Although doctors are free to establish their practice wherever they choose, grouping programmes (health centre) seek to encourage practitioners to establish their practices in deprived or isolated areas, in order to guarantee universal access to out-patient care. Dental surgeons Dental surgeons have their own professional association and comply with the dentistry code of ethics. The training period lasts between six and eight years in a training and research unit. With 40,000 practitioners, France has around 65 dental surgeons for 100,000 inhabitants. Although most professionals are in private practice, around 8% of practitioners are employees in treatment institutions, where they are primarily able to carry out major dentistry operations. Midwives Midwives, who hold a State diploma delivered by the French medical Training and Research Unit (Unit de Formation et de Recherche, or UFR), are actively involved in preventive measures and in the examinations required so that the pregnancy, delivery and the postdelivery period all go smoothly. In the event of complications or abnormal delivery, they are assisted by a doctor. There are currently around 18,000 midwives in France. Around 80% of them are employed in treatment institutions and 12% practice on a private basis, in a surgery or as a group.
NEW PROCEDURES
Attending doctors and the co-ordinated treatment path Since 2005, any insured person who is aged 16 or over is encouraged to choose an attending doctor for initial appointments, whether they are general or specialist practitioners. In fact, people generally tend to choose a general practioner who provides basic treatment. In addition to building a lasting and trust-based relationship with the patient, these measures enable a co-ordinated treatment path to be put in place: after the initial consultation, the attending doctor refers the patient to a specialist, if necessary. Financial penalties are incurred by insured persons if they consult a doctor outside their treatment path and if they have not chosen an
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attending doctor. Thanks to a better dissemination of information and improved coordination between the different practitioners, the patient avoids the useless duplication of medical examinations like blood samples and X-rays. This system also enables the build-up of prescriptions to be avoided, as well as the risk of interactions that are damaging for the patients health. The treatment path procedure enables the patient to take responsibility for his treatment consumption and to co-ordinate the healthcare players prescriptions. In the long term, the path should contribute to controlling healthcare expenditure. The insured person is not fully reimbursed outside the co-ordinated treatment path. In contrast, the patient is not penalised financially if he consults certain specialists directly, like gynaecologists, ophthalmologists, or psychiatrists. The same goes for emergency situations and situations where remoteness is a factor. The attending doctor procedure is aimed at all those covered by the social security system (38 million people) and at private doctors, i.e. around 114,000 healthcare professionals, including 53,000 specialists.
Contracts for Improving Individual Practices (Contrats dAmlioration des Pratiques Individuelles, or CAPI).
Since June 2009, doctors have been able to a contract to improve their individual performance. This procedure is part of the programme aimed at changing practices and improving treatment quality. By adopting this approach, the doctor benefits from regular monitoring (monthly indicators linked to drugs and quarterly indicators for all targets), access to data via a personal online account and help with raising patients awareness about national prevention campaigns (diabetes, cancer, etc.). In return, the doctor receives additional annual compensation, which takes into account his success rate in terms of meeting his targets, the progress made in his practices and the number of patients registered, i.e. a compensation amount ranging between 2,000 and 7,000. At the end of 2009, 12,600 doctors had already joined the programme, i.e. 30% of the healthcare professionals concerned by this practice assessment and improvement programme.
B - A highly regulated profession

Training In France, the number of trainee doctors is set by an annual quota known as the numerus clausus. That quota is set every year by ministerial decree and changes according to the French
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populations healthcare needs. The number of trainees is divided between the different medical training and research units. In 2009, 7,400 students in French universities as a whole were allowed to continue their studies after their first-year examinations in the first stage or training. These first-year examinations are eliminatory and can only be sat twice. Medical studies consist of three stages and usually last ten years. After of the house doctor examinations at the end of the second stage, students choose their specialisation, depending on their ranking and their preferences: the final stage for general practitioners lasts three years; for specialists the final stage lasts five years on average. Since 2002, all doctors (private, employees and hospital doctors) have been required to receive ongoing medical training, known as Continuing Professional Education (Dveloppement Professionnel Continu, or DPC) in order to maintain their expertise and update their knowledge of new care practices and techniques. This process involves subscribing to specialist journals, attending conferences and seminars, as well as following professional training courses. Moreover, practitioners are assessed every five years, according to criteria drawn up jointly by the National Health Authority and professional bodies for each specialisation. Medical agreements The funding of out-patient care (fees, drug prescriptions and other medical services, and compensation for medical leave of absence) represents 47%2 of health insurance expenditure. In accordance with market principles, the State has gradually introduced procedures to regulate that expenditure, in the aim of controlling the use of national healthcare resources whilst demanding quality treatment. The relationships between the health insurance funds and each profession that is part of the public healthcare service are governed by a statutory agreement. These agreements between the National Union of Health Insurance Funds (lUnion Nationale des Caisses dAssurance Maladies, or UNCAM) and medical trade union organisations, are drawn up for a period of five years, and primarily determine the fees for medical treatments and doctors financial compensation, as well as the terms and conditions for funding compulsory training programmes and specific aspects of the treatment path. Since 2004, the National Union of Healthcare Professionals (Union Nationale des Professionnels de Sant, or UNPS) has been responsible for negotiations with the National Union of Health Insurance Funds (UNCAM) and the National Union of Top-Up Health
2 - Excerpt from 2008 Facts & Figures for the health insurance industry
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Insurance Organisations (Union Nationale des Organismes dAssurance Maladie Complmentaire or UNOCAM). Moreover, the Union of Private Doctors (Unions des Mdecins Exerant Titre Libral, or URMEL) contributes to improving the management of the healthcare system, working together with the National Health Authority (HAS).
Rate tranches
Refundable rate tranche sector, known as Tranche 1: an approved doctor undertakes to comply with the regulatory rates ( 23 for general practitioners and 27 for specialists in 2011) and is prohibited from charging any additional fees. In exchange, health insurance funds fund almost two-thirds of social security contributions, and reimburse 70% of the patients costs within the coordinated treatment path framework (except for long-term illnesses and other specific cases). Three quarters of doctors are covered by Tranche 1, including 91% of general practitioners and 62% of specialists. The differential fee tranche, known as Tranche 2: the approved doctors fees are not regulated. Doctors who previously worked in treatment institutions often make this choice when setting up in private practice for the first time. The health insurance fund does only reimburse the patient according to the statutory rate. This tranche covers 38% of specialists, among others. The unregulated tranche, known as Tranche 3: The doctor is not bound by an agreement. The health insurance fund bases its reimbursement on a mandatory and variable rate depending on the nature of the treatment (less than 1 for appointments and 16% of the refundable rate for specialist treatments). The optional tranche: this new rating category - reserved for approved doctors - aims to combine regulated and unregulated rates within the same tranche. The practitioner could invoice 30% of his treatments at the social security rate and 70% as unregulated fees (below certain ceilings). This tranche is very recent, as the tripartite memorandum of understanding between the UNCAM, the UNOCAM and the CSMF was only signed in October 2009.
Regional distribution In terms of doctors per capita, France remains within the European average with 290.3 practitioners for 100,000 inhabitants in 2009. In accordance with the principle of free choice of practice location for private doctors, the geographical distribution of practitioners has not been regulated by the public authorities, and France has seen a decline in the number of doctors per capita in certain isolated or deprived areas. Despite the continual relaxation of the numerus clausus and the implementation of
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incentive measures to encourage doctors to establish their practice in the regions identified, inequalities remain and are likely to worsen in the coming years. In order to monitor healthcare professional numbers on a permanent basis and to draw up forecasts, the State founded the National Observatory for the Demographics of Healthcare Professionals (Observatoire National de la Dmographie des Professions de Sant, or ONDPS). Current forecasting models have become much more sophisticated, in order to combine multiple parameters. Those parameters include increasing demand for treatment as the French population ages and practitioners from the baby-boom generation retire. They also factor in the changing behaviour of the medical body, due to the increasing number of women in the profession, and the reduction in working hours, as well as the abandonment of certain areas or medical specialisations. The studies also take new skills and technological progress into account. In order to provide a practical solution to this geographical imbalance, the State is encouraging healthcare professionals to form groups or become involved in setting up Multi-Disciplinary Health Centres (Maisons de Sant Pluridisciplinaires, or MSP) in isolated areas, as well as emergency surgeries to guarantee treatment continuity. The Hospital, Patients, Healthcare and Regions (Hpital, Patients, Sant et Territoires, or HPST) Law will go even further: doctors practising in an area with surplus provision will be required to provide support to practitioners in under-resourced areas; failing which they will be required to pay a levy.
II - Paramedical and similar professions

Nursing professionals are actively involved in patient care alongside healthcare professionals. Most of these professions are regulated by the CSP and may have a professional roll, as is the case for nurses.
A- The regulated paramedical professions

Nursing care The number of nurses has increased consistently since the 1970s and especially in the
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last few years, due to the relaxation of quotas (30,000 in 2004). There are now around 480,000 nurses. Most professionals are women and the great majority (almost 90%) work as hospital employees. The profession is very diversified and includes a general track and three specialisations: the operating block, in order to assist the surgeon (6,500), anaesthesia, for the safety of the equipment and the surgical intervention (7,500) and nursery nursing to promote the development of young children (14,000). The nurse, who is at the patients service, supports patients and is involved in their care through a high number of health and welfare interventions. The other regulated professions Medical imaging professionals, who usually work in a hospital environment, as radiologists, scanner, or MRI scanner operators, or who are involved in radiotherapy treatments, are placed under the responsibility of a doctor and practice on medical prescription. Jobs in the physical re-education and rehabilitation sector are very varied: the physiotherapist works on functional re-education, the speech therapist solves written and oral communication problems, the chiropodist treats orthopaedic conditions and the optician designs and sells glasses and ancillary supplies. A diploma delivered by a Government-approved institute is required to work in these professions. These treatments are delivered on medical prescription.
B- The other professions

Patient care includes other roles besides these traditional roles. Psychological care and education Psychologists work with people suffering from mental problems on a preventive or treatment basis. In addition to practising on an independent basis, they work in various organisations: hospitals, schools or workplaces. Other roles, like educational specialists or team leaders are necessary to help individuals achieve psychological well-being or social integration. Laboratory jobs Medico-technical treatments are provided by biomedical analysis technicians. These biological tests are required to establish diagnoses or to make sure that a treatment is
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not toxic. Chemists assistants also play a major role in chemists and hospitals: they prepare the drugs prescribed by the doctor, deliver the drugs and make sure that the stated prescription dosage is followed. There are various areas of intervention: while 8% of dieticians practice in a surgery and collaborate with doctors, other professionals work with researchers in research institutes or in the pharmaceutical industry and some work in hospitals or in the collective catering field. Nursing assistants The nursing assistant supports dependent patients in their daily activities (hygiene and comfort) under the responsibility of a nurse, and provides treatments to ensure patients independence. There are over 456,000 nursing assistants in France, working in hospitals, in patients homes in the context of in-home hospital care, and in the welfare sector. As part of a multi-disciplinary team, the nursing assistant is involved in preventive, curative and palliative treatment. Nowadays, the nursing assistant is increasingly called upon to work with the elderly. In treatment institutions and medico-social organisations, Qualified Hospital Service Facilitators (Agents de Services Hospitaliers Qualifis or ASHQ) take care of hygiene and maintaining the premises and the equipment. They also contribute to the comfort of patients during their stay and help the nursing assistant if necessary. Patient transport The ambulance driver is responsible for transporting patients or injured people for treatment and diagnosis. These journeys are made on medical prescription or at the request of the emergency services. If emergency services are required, the ambulance driver assists the emergency medical team and relays information about the patient to the hospital services. An ambulance driver can work in the private, commercial or notfor-profit sector (Red Cross) or for the public hospital sector. Medical equipment Depending on the area of the body that is affected, several specialists will be involved in order to design and build prostheses for patients: the ocularist works on false eyes, the dental technician designs the dental prostheses ordered by the dental surgeon and the orthoprothesist takes care of patients who have had a limb amputated. All these treatments are also provided to the disabled.
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CHAPTER 4:
Treatment institutions
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CHAPTER 4: Treatment institutions

I - The hospital system

A - The public hospital service
Up until the end of the 19th century, the hospitals main role was that of a welfare institution - offering refuge to the destitute - before becoming a healthcare and research institution. Several reforms have put the operating principles of the modern hospital system in place. The law of December 31st 1970 guarantees the notion of Public Hospital Service, (Service Public Hospitalier, or SPH) based on the following major principles: equality of access and treatment, continuity of treatment, obligation to adapt in order to ensure an optimal quality of treatment throughout the country. The Law of July 31st 1991 introduced the principle of a single hospital system, by awarding joint public interest assignments to all treatment institutions, in both the public and not-forprofit private sector. Those assignments fall into four categories: treatment, patient information, public health assignments and the assessment and analysis of the work performed. In addition to providing preventive, curative and palliative (pain relief) treatment, the hospital ensures that the patient is cared for on an ongoing basis following an admission to or a stay in hospital. In addition, the SPH is involved in university teaching, and in ongoing training for healthcare professionals, as well as in clinical research and treatment innovation. In order to promote a more consistent organisation of treatment provision, the HPST Law abolished the classification of institutions that are part of the public hospital service. Public service mandates can now be awarded to any private institution (either on a voluntary or compulsory basis), which will then benefit from the new single Public Interest Private Healthcare Institution status (Etablissement de Sant Priv dIntrt Collectif, or ESPIC). The distinction between the for-profit and not-for-profit private sectors still remains.
B- The hospitals duties

Access to healthcare Nowadays, a hospital provides care to patients without any discrimination on grounds of race, gender, or income level. In an emergency situation, any destitute person - with no identity documents or health insurance certificate - will be taken care of if their state of health requires it. Patients are admitted 24 hours out of 24 and every day of the year.
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Prevention In admitting several million people per year - patients or visitors - the hospital is also the focal point for identifying diseases. In fact, the hospital plays a major role in disease prevention and provides information to various audiences - patients, visitors and healthcare professionals-, on a daily basis. By creating networks for players in the local healthcare and welfare sector, the hospital contributes to the implementation of preventive and curative measures in various fields: obesity, alcoholism, smoking, road safety, etc. Both inside and outside the institutions, many health promotion initiatives are taken in order to raise patients awareness and educate them. Continuity of treatment In accordance with the Public Health Code, institutions that play a role within the public hospital service admit new patients day and night thanks to combined services. Within the hospital, that task is assigned to the emergency services and to the ongoing care services staffed by doctors and medical teams who are legally bound to provide such services. In the event of overload, the patient is referred to a neighbouring institution, thanks to the networking of hospitals in the same region. Moreover, a minimum service is always provided in the event that the staff goes on strike. Quality of treatment Quality of treatment is in line with the aim of continually improving the service provided to the patient and the institutions performance. Each institution adopts a quality approach and, in so doing, adheres to a set of standards in terms of equipment, staff qualifications, and of the organisation of treatment and the admission of patients. Beyond public health issues, these initiatives encourage the institution to optimise the way in which it is organised and to adhere to its financial targets. The assessment of operations and practices, which is carried out by independent experts, aims to check safety levels and treatment quality. In fact, every hospital has been involved in an accreditation process for around the past ten years; the accreditations are delivered by the National Health Authority (HAS). University teaching and ongoing training Working together with university medical departments, Frances 29 Teaching Hospitals (CHUs) are involved in public medical, pharmaceutical and odontological teaching, as
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well as in post-graduate training (specialised professional teaching for graduate doctors). Doctors initial training is in three stages, with several clinical internships and house doctor examinations to choose an area of specialisation. Teaching hospitals also contribute to the ongoing training of GIP public hospital staff and of healthcare professionals who are not doctors (nurses, nursing assistants, nursery assistants, chemists assistants, etc.). Moreover, hospital and private practitioners are bound by law to take part in ongoing training programmes on an individual basis. This requirement, which is more than an ethical obligation, enables them to keep up their expertise, to gain new knowledge and to adapt to changes in treatment techniques. Research In addition to being a place for teaching and training, the hospital is actively involved in medical, dental and pharmaceutical research. In terms of treatment innovations and human trials, teaching hospitals (CHUs) rely on the expertise of the French National Health and Medical Research Institute (Institut National de la Sant et de la Recherche Mdicale, or INSERM) and benefit from a recognised multi-disciplinary network: clinical research teams and centres, partnerships with specialist institutes, cooperation with the INSERM and the National Centre for Scientific Research (Centre National de la Recherche Scientifique, or CNRS). As a strategic platform for medical advances, the hospital has become an essential partner for players in the pharmaceutical and biomedical industries.
II - the French hospital sector

The French hospital sector1 consists of 2,877 treatment institutions with a capacity of around 448,500 full-time hospital beds and around 53,000 places reserves for patients admitted on ad hoc basis. The hospital sector is divided into three categories: public institutions, not-for-profit institutions and commercial institutions, which are known as clinics.
1 - Excerpt from Hospitalisation and the organisation of treatment in France (2006).
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Share of field depending on:
Health care establishments (1)

Public health care establishments (2) Private health care establishments (3) Establishments previously financed Other private establishments by global funding (4) Short-term care establishments Cancer care centres Mental health care establishments (6) Ongoing and rehabilitation care establishments (7) Long-term care establishments Home hospitalisation establishments Dialysis establishments Radiotherapy establishments Public sector Private sector Non-profit sector Profit sector Expenditure target concerning MCO (ODMCO) activities Funding by activity (8) Provisional additional annual allocation (9) Tasks of general interest and assistance in contractualisation / Specific allocations Sickness insurance expenditure target concerning SSR National quantity target and psychiatric activities (10) concerning SSR and psychiatric Annual funding allocation activities
Category of establishment
Status Modes of financing
A - Public health institutions

The 1,006 French public health institutions account for around 65% of hospital beds (291,483 beds) and outpatient admissions (32,626 places). Public hospitals, which are State-owned companies, perform a public interest mandate and are attached to a local authority, usually a municipality. Although they enjoy managerial and financial independence, they remain under State Control and must comply with the Public Tender Code, among other matters. The public sector includes institutions operating in the patient-care (hospitals), welfare (retirement homes) and medico-social (specialist care centres) fields. The generic public hospital description distinguishes between two main categories of public health institutions: Regional Hospital Centres (Centres Hospitaliers Rgionaux, or CHR) on the one hand and Central Hospitals (Centres Hospitaliers, or CH) and local hospitals, on the other. They are financed in the same way, but their role and their scope of action are different. Regional Hospital Centres: 31 institutions A hospital centre with a regional focus, the Regional Hospital Centre provides a series of specialist treatments thanks to a high-performance specialisation platform (specialised
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Field: The whole of France. Source: Ministry of Health, General Treatment provision Department 2008
Other establishments (5)
Psychiatric hospitals
Regional hospitals
General hospitals
Local hospitals

staff and surgical, and imaging equipment, etc.). In addition to providing day-to-day care for the local population, the regional hospital serves as a resource for other institutions in the region. With over 200 hospital complexes, almost 3,000 services or departments, a capacity of 80,000 beds and around 7,000 out-patient places, regional hospitals account for 35% of the activities of the French public hospital sector. As part of an agreement with one or several training and research units, most Regional Hospital Centres have Regional Teaching Hospital status (Centre Hospitalier Rgional Universitaire or CHRU). They therefore perform a triple role: patient care, teaching and research. Frances 29 regional teaching hospitals are generally located in built-up areas (Paris, Lyons, Strasbourg, Marseille, etc.) or in major cities (Nantes, Grenoble, Rennes, Saint-tienne, etc.). General central hospitals: 611 institutions Central hospitals account for over half of hospital beds (160,000 beds) and the majority of public sector day admissions, with 11,500 day beds. The central hospital is the areas lynchpin hospital and is responsible for the local population. It issues diagnoses and provides a series of treatments linked to acute conditions in the medical, obstetrics and surgery fields. Following a stay in hospital, it provides follow-up and rehabilitation treatment and long-term treatment. Among these Central Hospitals, 91 institutions specialise in psychiatric care. The 520 other institutions perform medical, surgical and obstetric work. Local hospitals: 346 institutions Local hospitals account for a third for the hospital pool and around 4% of public sector beds, with 21,600 beds. Usually located in rural municipalities, they provide short-term local medical treatment. They correspond to the first level of hospital care and also specialise in medium and long-term stay procedures, like follow-up and rehabilitation treatment, taking care of elderly dependent people and in-home care procedures.
B - Private institutions
In 2006, the private hospital sector included around 1,871 institutions, providing around 157,000 beds and 20,500 day-care places. Among private institutions, a distinction is made between those that aim to make a profit (clinics) and those with no commercial aims, which usually contribute to the public hospital service.
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For-profit private institutions: 1,067 establishments. These institutions have 94,000 beds and around 11,000 day-care places. These clinics, which are commercial companies with shareholders equity and subject to private legal statutes, are often economic interest groups (EIGs) or belong to groups that include several institutions. Private practitioners work there. To the extent that they have to meet an areas patient care targets, clinics are also subject to a prior authorisation system operated by the local authorities (set-up, extension, heavy equipment, etc.). In certified private clinics, the patient is reimbursed at the normal rate. In contrast, the patient may be reimbursed at a lower rate in uncertified clinics. Private not-for-profit establishments: 804 institutions Private not-for-profit institutions account for 51,000 beds and 7,750 day places. These institutions, which have cross-divisional expertise in the patient care, social and medicosocial fields, provide overall patient care. They are usually managed by associations, mutual benefit companies or foundations, and benefit from independent management. However, their funding model is similar to the model for public hospitals, and they comply with the same patient care requirements. In addition to In-Home Nursing Care Services (Structures de Soins Infirmiers Domicile, or SSIAD) or Nursing Homes for Elderly Dependent People (tablissement dHbergement pour Personnes Ages Dpendantes, or EHPAD), the private not-for-profit sector provides a large part of Frances in-home hospital care. Over two-thirds of these organisations are involved with the Public Hospital Service (565 against 239) including twenty Regional Cancer Research Centres (Centres Rgionaux de Lutte contre le Cancer, or CLCC) distributed throughout France (3,000 beds). In addition to their research and teaching duties, these centres play an essential role in combating cancer and contribute to improving patient care.
C - Specialist institutions and alternatives to hospitalisation

Psychiatric care Taking care of patients with mental health issues or psychiatric problems requires specialist facilities and treatment. The public psychiatric system is organised into psychiatric sectors, in order to provide patient care, in an institution or at home, that suits the requirements of different patient profiles: adults, people in detention centres,
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children and teenagers. In addition to meeting treatment access and continuity requirements, sectorisation follows a dual patient care system, either on an in-patient or out-patient basis, as the nursing staff is called upon to work inside and outside the institutions. The French healthcare system includes 91 hospital Specialist Psychiatric Centres (Centres Hospitaliers Spcialiss (en Psychiatrie), or CHS), as well as 240 private institutions dedicated to fighting mental illness. The growth of remote alarm systems and the co-ordination of treatment between several specialists are enabling a sharp increase in alternative patient care methods, which do not include hospitalisation. Among similar organisations, Medico-Psychological Centres (Centres MdicoPsychologiques, or CMP) provide out-patient and in-home care and organise prevention initiatives. We also find specialist organisations in the social re-insertion and patient rehabilitation fields, like therapy centres or communal housing. Facilities and medical monitoring for dependent elderly people Alongside traditional hospitalisation methods, there are organisations in the patient care and medico-social fields that are dedicated to taking care of elderly dependent people - on a full-time or sometimes part-time basis: Nursing Homes for Elderly Dependent People (EHPAD). Regardless of whether they are attached to a treatment institution, they can participate in the Public Hospital Service (SPH) or operate in the for-profit sector. The elderly are admitted according to their state of health and their level of independence or isolation. Patients may be admitted from the age of 65 onwards - 60 for people who suffered an accident in the workplace - but the average age of admission is currently over 83. Finally, Nursing Homes for Elderly Dependent People set aside places in order to provide temporary daytime or overnight accommodation to elderly people whose condition requires one-off assistance. This system primarily enables close relatives (carers) looking after an elderly person who is dependent or suffering from Alzheimers disease to be relieved on an ad hoc basis. Depending on their profile, elderly dependent people are taken care of in treatment institutions or medico-social facilities.
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The treatment sector

There are different levels of patient care. Long-Term Treatment Units (Units de Soins de Longue Dure, or USLD) admit dependent patients requiring constant medical supervision, which lasts for a year and a half on average. These institutions also provide Short-Term Geriatric Care (Soins Griatriques de Court Sjour, or MCO) on a full or part-time inpatient basis, as well as Follow-Up and Rehabilitation Care (Soins de Suite et de Radaptation, or SSR) for medium-term stays.
The medico-welfare sector

Whether or not they are attached to care institutions, retirement homes - Rural Retirement Homes for the Elderly (Maisons dAccueil Rurales pour Personnes Ages, or MARPA) in rural areas offer permanent or temporary accommodation, as well as related collective services (hygiene, catering, laundry, activities, etc.). Sheltered accommodation and serviced residences offer accommodation in flats with the possibility of enjoying collective services.
Alternatives to traditional hospitalisation Over the past few years, in-home hospitalisation methods or temporary admission to a nursing home for elderly dependent people have been developing in order to improve the way in which they meet dependent patients expectations, to give carers a period of respite, and to enable better regulation of the hospital treatment on offer. Among other measures, patients can benefit from In-Home Nursing Care Services (SSIAD) for medical supervision and other hygiene and paramedical treatments. All these services are covered - either in full or partly - by the social security system. Nowadays, keeping patients in their own homes has been made possible by technical advances (remote monitoring and alarm systems) and by efficient co-ordination between healthcare professionals and social services (organised transports, meals on wheels, assistance with housework and maintenance, in-home supervision, etc.)
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III - Managing care institutions

A - The instruments of hospital policy
The organisation and planning of hospital treatment provision comply with three imperatives: achieving consistent distribution by area, responding to the populations needs and controlling healthcare expenditure. The public authorities have implemented several tools to set the level of equipment required by the institutions, to set a framework for their expenditure and to understand and assess their operations. Hospital planning The Regional Public Health Organisation Programme (SROS) is the patient care planning tool. The programme sets patient care priorities at the regional level over a period of five years, with the aim of rationalising hospital treatment provision in the area and improving the quality of treatment. The programme oversees the gradual organisation of specialist platforms and promotes alternative solutions to hospitalisation (keeping patients at home and local activities). Regional Hospital Agencies (AHS) were responsible for allocating the hospital budget in their area, for delivering authorisations and for cooperation between public and private care institutions. As part of the latest hospital reform, Regional Hospital Agencies (AHS) were replaced by Regional Health Agencies (ARS) in 2010; those agencies now manage regional healthcare policy within a broader medico-social framework. Several plans will co-exist within the regional healthcare plan managed by the Regional Health Agency (ARS): the regional prevention programme, the regional patient care organisation programme (hospital and out-patient sections) and the medico-social programme. Certification and information systems As part of an initiative to assess operating levels and practices, the National Health Authority (HAS) has awarded renewable certificates to hospitals and clinics. Moreover, the hospital information system brings together a set of tools for surveying all the certified resources (professionals, institutions and equipment). Finally, the information system medicalisation project assesses hospitals activities in order to allocate budget resources according to the medical nature of hospital stays.
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Funding The level of public sector hospital expenditure is divided into regional allocations, which are distributed in turn by the Regional Health Agencies (ARS). Moreover, the State provides support for investment in hospitals through multi-year funding plans that amount to several billion euros. The old allocation system, which was deemed to be unbalanced and unrepresentative of institutions activities, was recently replaced by a new funding method: rating per activity, or T2A.
Establishing rates per activity is an effective reorganisation tool.

Since 2004, a new system for allocating resources has applied to all institutions, whether public or private: Rate-Setting per Activity (Tarification lActivit, or T2A). Henceforth, it is the medical activities (nature and quantity of the treatments performed) that determine the hospitals resources. Rate-setting per activity stems from a mixed funding system that differentiates between treatment and public interest assignments (research, teaching, etc.). The former are funded per procedure, the latter benefit from a special allocation. Ratesetting per activity only concerns medical, surgical and obstetric procedures, and not follow-up and rehabilitation services, psychiatry and long-term care, which are funded on a different basis. By introducing a larger medical component to funding, rate-setting per activity tends to make the players take more responsibility and to develop steering and internal management tools. Its aim is to harmonise funding methods and to allocate resources, between different medical sectors and hospitals, in an equitable manner. Ratesetting per activity will be gradually applied to other treatment sectors.
B- Towards a new form of hospital governance

Before 2009 and the Hospital, Patients, Health and Regions Law Hospital administration As a company that enjoys administrative and financial independence, a hospital is a public organisation with management bodies - a board of directors, an institution director appointed by the Minister and an executive committee, as well as several consultative committees, including the Institutional Medical Committee (CME) (Commission Mdicale dEtablissement, or CME), made up of the practitioners representatives, the Institutional
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Technical Committee (Commission Technique dEtablissement, or CTE), which includes trade union representatives, and the Hygiene, Safety and Working Conditions Committee (Comit dHygine, de Scurit et des Conditions de Travail, or CHSCT) . Although the decision-making process varies according to the institutions status, private organisations have adopted management and consultation methods that are quite similar and are organised in a similar way to public hospitals. Medical organisation The overall organisation of the hospital is consistent with the institutions medical plan, as well as with the Multi-Year Aims and Means Contract (Contrat Pluriannuel dObjectifs et de Moyens, or CPOM) approved by the Board of Directors. The hospital is organised into clinical and medico-technical clusters, which are in turn divided into functional services and units that call upon specific medical and paramedical skills. Each cluster is headed by a practitioner appointed for five years and responsible for drawing up an internal plan for the organisation and assessment of his cluster. The cluster organisation method is in line with the principle of synergies between different branches of medicine and treatment targets. It also promotes the optimisation of the economic operation of the institution by simplifying relationships with support services (medical imaging, laboratories and chemists). The impact of the 2007 hospital plan on hospital governance In addition to introducing rate-setting per activity, the 2007 hospital plan aims to modernise hospital governance by broadening institutions independence and bringing hospital services together within activity clusters. After 2009 and the Hospital, Patients, Health and Regions Law The Law of July 21st 2009 on Hospital, Patients, Health and Regions (HPST) put in place a new organisational structure for hospitals to meet the current patient care challenges: modernising treatment institutions, access to quality treatments for all, reinforcing prevention policies and a new organisation of the healthcare system by area. The aim of the HPST is to guarantee a range of graduated treatments and boost the efficiency and safety of healthcare services. In terms of prevention, Therapeutic Patient Education (TPE) and combating risky behaviour are prioritised. These procedures primarily target the factors behind chronic illnesses and cancers, like smoking, alcohol and obesity. The changes to hospital governance were as follows:
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A new governance for public institutions Modernisation of internal operating methods involves managers taking more responsibility and creating new steering committees. The supervisory board replaces the board of directors and sees its assignments refocused on strategic decisions, assessment and checks. An executive board replaces the executive committee. The board is consulted about major decisions, adopts the medical plan and draws up the institutional plan. The chairman of the board is the head of the institution and the vice-chairman is the chairman of the Institutional Medical Committee (CME). The vice-chairman draws up the medical plan in collaboration with the head of the institution. He co-ordinates medical policy and is the joint decision-maker on quality, treatment safety and patient care issues. The Institutional Medical Committee (CME) switches its focus to the medical plan and treatment quality and safety action programmes. The number of consultative bodies is reduced, as some are absorbed by the Institutional Medical Committee (CME). The head of the institution is responsible for implementing the institutional plan and for the Statement of Forecast Income and Expenditure (Etat des Prvisions de Recettes et de Dpenses, or EPRD). In addition to relaxing the procedures for appointing hospital staff, the law authorises the appointment and the recruitment of managers and practitioners who are not from the public hospital service. In contrast, the head of the Regional Health Agency (ARS) does not appoint the heads of hospital institutions, but may only suggest a list of three approved persons. He is appointed by the National Management Centre. When the cluster contract is introduced, the cluster heads see their internal management responsibilities increased (organisation of human resources and logistics). In terms of quality and safety, the institution undertakes to make its annual results public by using monitoring indicators. Reinforcing public health co-operation tools In order to promote co-operation, the reform allows for rebuilding the treatment provision on a group model, by creating local hospital communities. Public institutions within a single area are called upon to co-operate under the guardianship of a benchmark hospital that is responsible for common strategy and has a significant amount of technical resources. The implementation of a consistent medical plan at the local level involves the delegation of certain capabilities to the benchmark hospital and the pooling of resources. Along similar lines, co-operation between public and private institutions is made easier by the creation of Public Health Co-operation Groups (Groupements de Coopration Sanitaire, or GCS). The French National Agency for Supporting Medical Institutions Performance (Agence Nationale
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dAppui la Performance des Etablissements, or ANAP), now assists institutions with their internal modernisation efforts in order to improve the service provided to patients. Organisation of the healthcare system by area and access to treatment Regional Health Agencies (ARS) have replaced Regional Hospital Agencies (AHS) as the authorities responsible for implementing national healthcare policy in the regions and have become the single contact point for healthcare professionals. Their prerogatives extend to general practitioners and to the medico-welfare sector and enable barriers between existing systems (hospital, out-patient care and the medico-social field) to be eliminated. The Regional Health Agency (ARS) management team approves the regional healthcare plan after consulting the organisations in the area that bring together healthcare professionals and players in the medico-welfare sector. The regional healthcare plan determines the priorities and the terms and conditions for implementing regional prevention and treatment organisation programmes, as well as the range of medico-social treatment. In addition to improving the traceability of patient care activities and the pooling of information, the French Shared Information Systems Agency (Agence des Systmes dInformation Partags, or ASIP) promotes the roll-out of innovative tools like remote X-rays or remote medical treatment. In addition to overseeing a fair distribution of doctors and patient care systems in the area, the Regional Health Agency (ARS) encourages the co-ordination and the permanent availability of out-patient and hospital treatment. Moreover, Regional Public Health Organisation Programmes (SROS) include an out-patient component, in order to optimise patient care resource networks and to promote partnerships between the various local players.
Regional health policy at regional health project level

(Regional Health Authority) Regional health project Regional prevention structure Regional health structure (hospital and ambulatory) Medical-social structure
Structure from Health Ministry Site
24-hour care availability + Universal access to health care + Efficiency of health organisations + Quality and safety of care
ARS
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CHAPTER 5:
The pharmaceutical sector and the healthcare industry

45
CHAPTER 5: The pharmaceutical sector and the healthcare industry

I - The pharmaceutical sector in France

Although the status of apothecary was created in the 18th century, the medical and pharmaceutical sectors remained very close in the 20th century, and certain specialist practitioners, such as veterinarians, dental surgeons or midwives, can still supply only a limited number of drugs. In France, the pharmaceutical sector is a multi-disciplinary business that includes seven sections, including certain major positions: dispensary pharmacists and distributing pharmacists, hospital pharmacists, industrial pharmacists and biological pharmacists. The pharmaceutical sector is regulated by the French Public Health Code. In addition to regulating the manufacture and distribution of drugs, the State sets their sales price and the related distribution margins. Although generalist chemists are private companies, their location is regulated by the 1941 legal framework - renewed in 1999 -, which specifies the conditions for setting up, transferring ownership of and grouping dispensing chemists. Any outlet opening is subject to prior authorisation by the authorities, delivered by the Prefect (a license). Geographical and socio-demographic restrictions aim to distribute chemists harmoniously throughout France, especially in sparsely inhabited regions or in so-called sensitive areas. This means that, at the national level, there is around one chemist for every 2,800 inhabitants, compared with the European average of one dispensing chemist for 3,300 inhabitants. Moreover, if dispensing chemists may operate as a company, retail chains remain prohibited: every institution is independent and remains owned by a sole proprietor.
A - The dispensing chemist

As the owner of a chemists, a dispensing chemist is a retailer as well as being selfemployed. As a French of European national and the holder of a State doctor of pharmacy diploma, he is registered on the roll of the competent professional authority, the French Association of Pharmacists. This organisation draws up a code of business ethics in order to guarantee the independence of the profession, as well as compliance with its duties. The chemist is particularly bound by professional secrecy. As the owner of a dispensary, he is the monopoly distributor of drugs for human consumption and also sells veterinary drugs, herbal medicines, toiletries and beauty products. As a person approved to prepare
46

prescribed proprietary drugs, the chemist supplies drugs and checks prescriptions. In addition to advising the customer and checking the dosage of the drugs supplied, the chemist must warn the customer about potential incompatibilities between certain drugs or with other commonly used substances, like alcohol. The chemist may also collect unused drugs brought in by customers free of charge, so that they may be destroyed under proper safety conditions. If a patient cannot move, the general chemist can supply the prescribed drugs at home. Moreover, some chemists are led to participate in public health actions and in social services, through providing data on refunds to health insurance funds and to certain top-up bodies. Since July 2008, chemists may allow the general public access to certain drugs that may be supplied without a doctors prescription at the front of the counter. The aim of this measure is to promote self-medication.
Source: National Association of Pharmacists Demographic pharmaceutical brochure
Pharmacies per 100,000 inhabitants
Average
In Metropolitan France, there is an average of 36 pharmacies per 100,000 inhabitants
per 100,000 inhabitants
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B - The hospital pharmacist

The hospital pharmacist works in the in-house pharmacies of different types of institutions: public and private hospitals, medico-social organisations, prisons and military health care services. As the person responsible for the pharmacy business in these institutions, the hospital pharmacist is responsible for managing, purchasing supplies, preparing, checking, holding and supplying drugs and sterile medical supplies for patients admitted to the institutions. He oversees the quality and safety of the treatment, primarily by monitoring the risks posed by the medical supplies or the products unwanted side-effects. The hospital pharmacist may also contribute to the assessment of drugs in the context of clinical trials. Since 2004, in-house pharmacies have been allowed to sell drugs to out-patients: this system, known as hospital retrocession is a specific characteristic of the French healthcare system. Key numbers: As at January 1st 2009, there were 72,716 pharmacists in France: 28,148 owners of general dispensing chemists and 22,462 chemists in metropolitan France 26,217 chemists assistants (an employee who assists the head chemist in the preparation and supply of drugs) 5,303 hospital pharmacists 3,393 industrial pharmacists 1,362 pharmaceutical distributors 8,015 biological pharmacists
Source: National Association of Pharmacists Pharmaceutical demographics booklet
II The healthcare industry in France

A - Drugs
Given the risks inherent to their use, the drugs market is tightly regulated and all players in the sector are subject to strict regulation. Drugs have a specific legal status, awarded
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by the French Public Health Code, and are the subject of particular vigilance intended to guarantee their quality, effectiveness and safety. Certain drugs for benign conditions are supplied without a prescription and fall into the self-medication category. However, the vast majority of proprietary drugs requires a prescription from a healthcare professional - a doctor, a dentist, a vet or a midwife. The pharmaceutical industry also includes medical supplies that are healthcare products and that play a dominant role in treatment, as well as in the prevention and detection of diseases. Medical supplies include products and equipment with very different areas of application and are regulated by the French Public Health Code. In order to ensure optimum drug usage safety, their supply is subject to restrictions relating to the date and length of the prescription, together with the quantity supplied. Some proprietary drugs are therefore classified according to lists: List I: sold on presentation of a prescription within three months of issue. The number of renewals is indicated by the prescribing doctor for a period of up to one year. The boxes have a red rim. List II: sold on presentation of a prescription within three months of issue. The prescription is renewable for one year unless the prescribing practitioner indicates otherwise. The boxes have a green rim. Narcotics: sold on presentation of a secure prescription (accompanied by a narcotics voucher that the chemist keeps for three years). The length of the prescription is limited to 28 days and renewal is prohibited. Limited market availability Any supply and prescription of drugs, even in the context of self-medication, is subject to an administrative decision: the Marketing Authorisation (Autorisation de Mise sur le March, or AMM), which is delivered by the French Agency for the Medical Safety of Healthcare Products (Agence Franaise de Scurit Sanitaire des Produits de Sant, or AFSSAPS). The process, which is long and stringent, includes a series of toxicology studies and clinical trials on humans in order to determine a drugs benefits and safety level, as well as chemical, pharmaceutical and biological data proving its quality. The Marketing Authorisation (AMM) is not just a permission to sell the drug; it involves producing documents relating to the authorised drug: a summary of the products characteristics, information about its packaging, and finally, instructions for the user, which are
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systematically included in the products packaging. Issued for a period of five years for drugs where the benefit/risk ratio is positive, the Marketing Authorisation (AMM) is granted for precise therapeutic indications and conditions of use. Any changes to the proprietary drug require a new Marketing Authorisation (AMM) or an alteration to the Marketing Authorisation (AMM). The AFSSAPS issues two other kinds of restrictive permissions: the Authorisation for Temporary Use (Autorisation Temporaire dUtilisation, or ATU) intended for serious or rare diseases for which there is no appropriate treatment, and the Importation Authorisation (Autorisation dImportation, or AI), which precedes every importation of drugs necessary for conducting biomedical research.
Regulatory circuit for reimbursable drugs Marketing authorisation
issued by EMEA or General Directorate of AFSSAPS (French Health Products Safety Agency ) after consultation of Marketing Authorisation Commission
Improvement in Medical Service Rendered (ASMR) Medical Service Rendered (SMR)

opinion of HAS after assessment by the Transparency Commission
Registration on the SS (Social Security) list

decision of the Minister
Rate of reimbursement
decision by UNCAM (National Union of Sickness Insurance Offices)
Price
negotiation with CEPS (Economic Committee on Health Care Products)
Concomitant publication in the Official Journal Regulatory circuit for drugs sold to hospitals Marketing authorisation
Improvement in Medical Service Rendered (ASMR) Medical Service Rendered (SMR)

opinion of HAS after assessment by the Transparency Commission
Registration on the community list

Registration on the retrocession list or T2A (ActivityBased Financing)

Declaration of price
declaration to CEPS
Publication of lists in the Official Journal
Publication of lists in the Official Journal
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Source: LEEM web site (drugs companies)
issued by EMEA or General Directorate of AFSSAPS (French Health Products Safety Agency ) after consultation of Marketing Authorisation Commission

Rate structure and prescription The proprietary drugs included on the list of products that are reimbursed by the health insurance system are subject to a statutory rate structure. Margins on the drugs are set via a regulatory approach: their pricing is set through an agreement between the manufacturer and the French Economic Committee for Healthcare Products (Comit Economique des Produits de Sant, or CEPS). The rate structure is then the subject of a published ministerial decree in the French Official Record. The National Health Authority (HAS) transparency commission the ministers responsible for healthcare and social security on covering the costs of drugs (either through the social security system and/or their use in hospital), primarily in view of their Medical Benefit (Service Mdical Rendu, or SMR) which takes into account the gravity of the condition, the effectiveness and the undesirable side-effects of the drug, and its place within the care strategy, as well as the improvement in the Improved Medical Benefit (Amlioration du Service Mdical Rendu, or ASMR) that they are likely to provide compared with treatments that are already available. If the rate structure is regulated, the nature and volume of prescriptions remain at the sole discretion of the healthcare professional. A doctor must therefore manage a portfolio of 3,000 drugs, of which 500 are used regularly. The doctor receives regular information from laboratory medical representatives and through medical reviews, as part of his Ongoing Medical Training (Formation Mdicale Continue, or FMC).
PLEASE NOTE: THE NEW RESTRICTED PRESCRIPTION SCHEME

Due to their therapeutic characteristics, their costs or the risks associated with their use, some drugs are the subject of a restricted prescription. They are subject to a classification that is part of the Marketing Authorisation, which has four different schemes: The Hospital Stock (Rserve Hospitalire, or RH): innovative drugs that have potentially high risks. These drugs are supplied and administered during a hospital stay. The initial hospital prescription (Prescription Initiale Hospitalire, or PIH): a drug that has to be prescribed by a hospital doctor as part of a clinical diagnosis for the first time. Any general practioner can renew the prescription. That prescription can be issued directly by a hospital pharmacy or in a general dispensary.
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Drugs that require particular supervision (PS) during treatment: Egiven the drugs high level of toxicity and the seriousness of the potential side-effects, the prescription is subject to biological supervision in order to monitor the risk/benefit ratio (see p 50). They can be prescribed by any doctor. Drugs that can only be prescribed by certain specialist practitioners (SP): drugs that are difficult to handle and are prescribed for complex conditions by specialist practitioners. They are supplied in a dispensing chemists based on a so-called exceptional drugs prescription.
B - The pharmaceutical industry

In contrast to its European competitors, the French pharmaceutical industry has its roots in the dispensing chemists and not in the chemical industry, as in Germany. From the mid-19th century onwards, chemists began to develop new proprietary drugs in laboratories attached to their institutions. Their gradual consolidation within major groups gave birth to the French pharmaceutical industry, which operates in two main areas of activity: research and manufacturing. Today, the French pharmaceutical sectors companies and laboratories are represented by a professional organisation: the French Pharmaceutical Companies Association (Les Entreprises du Mdicament, or LEEM). A dynamic sector With revenues of 47.5 billion in 2008 (45% of which were generated by exports), France has been the leading European producer and exporter in the sector since 1995. The sector generated a positive trade balance of 7.1 billion in 2008. It employs over 100,000 people and is the leading French industry sector in terms of research and development, ahead of the aviation and space industries. The budget dedicated to research, which is estimated at 4.9 billion, represents around 12% of the sectors revenues. These research efforts are made all the more significant by the fact that it takes between seven and 12 years to bring a new molecule to market. Therapeutic advances, which amounted to 31 in 2008, are mainly focused on cancer, infections and rare diseases. Among the 326 companies surveyed by the French Pharmaceutical Companies Association (LEEM), 177 specialise solely in biotechnology. As a necessary lever for developing innovative therapies, these new
52

technologies enable time savings in terms of research and pharmaceutical manufacture. Medical supplies, which are state-of-the art products and equipment, represent a market of several billion euros in France and one which has shown consistent growth over the past few years. State support Faced with the increasing cost of research, and given the restructuring of the sector in the 1990s, the State has put in place a statutory agreement with the pharmaceutical industry, in order to maintain the advances made by French companies and their attractiveness. Beside research tax credits, several framework agreements define global drugs policy and relationships with the players in the pharmaceutical industry. In 2004, for example, the State created the Strategic Council for the Healthcare Industries (Conseil Stratgique pour les Industries de Sant, or CSIS) in order to promote the French pharmaceutical industry and support research, primarily through the creation of a biotechnology support fund of between 100 to 150 million, co-funded by private laboratories. Moreover, France is one of the first countries to adopt specific biomedical research legislation, in order to protect people participating in clinical trials. Known under the term of best clinical practice (Bonnes Pratiques Cliniques, or BPC), the legislation also aims to make the results from the different drug testing phases reliable and repeatable.
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FOCUS: drug advertising

Any information for a proprietary drug that has a promotional and lucrative purpose is subject to specific legislation so as to guarantee its proper use. Only drugs that have received a Marketing Authorisation (AMM) may be advertised. The law makes a distinction between two audiences: healthcare professionals and the general public. The general public: Drugs that are not subject to medical prescription and are not reimbursed by the health insurance system, as well as products like vaccines, on an exceptional basis; Prior authorisation from the AFSSAPS: the advertising permission; Obligation to attach a warning message and to refer users to their doctor in the case that symptoms persist; The message should not suggest that the drugs effectiveness is guaranteed and that it does not have any undesirable side-effects. Healthcare professionals: No prior authorisation from the AFSSAPS; Obligation to register with the AFSSAPS within a minimum of eight days after the advertising has been circulated to professionals; Following that registration, the AFSSAPS may require that the advertising is altered, order it to be suspended or prohibited, and require the dissemination of a rectification Significant consumption The French are still the largest consumers of medical treatments and products in Europe, consuming a total of 163.8 billion in 2007, i.e. 2,563 per inhabitant, including 522 for drugs. This high consumption, which has been multiplied by thirty in 40 years, justifies market regulation through several means: monitoring and regulating prices, recommending good prescription practices, stopping reimbursement of some products and promoting generic drugs, and initiatives for controlling medical prescriptions. Once a drug patent has expired (10 years in France), a copy of the original product may be developed and marketed: it then becomes a generic drug. In 2008, generic drug sales increased by 6%, reaching 10.2% of reimbursable drug revenues. In 2009, the increase in generic drug sales enabled the health insurance system to save 1 billion.
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CHAPTER 6:
Public healthcare policy

Although France has the longest life expectancy among the countries of the European Union, its avoidable mortality (before the age of 65) performance is still inadequate and there are also social and regional inequalities. In order to eradicate this paradox and guarantee the effectiveness of the prevention initiatives conducted on a national scale, France recently adopted a clear and consistent legal framework.
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CHAPTER 6: Public healthcare policy

I - A legal framework for public healthcare initiatives

The Law of August 9th 2004 on public healthcare policy caused fundamental changes in institutional procedures at the national and regional level. Lowering premature mortality rates and regional healthcare disparities is the focal point of the 2004 Law, which states that the State is responsible for defining healthcare policy. The text of the law promotes a dynamic prevention policy. It primarily reinforces the role of the French National Healthcare Prevention and Education Institute (Institut National de Prvention et dEducation pour la Sant, or INPES) and also supports screening and healthcare programme development initiatives. The Law of August 9th 2004 meets the rule of the Five Rs: Responsibility: The State guarantees healthcare protection and the initiatives of healthcare players. It defines healthcare policy every five years according to multi-year targets. Results: the Government accounts for the impact of its policy on the populations state of health every five years. Rationalisation: the organisational structures are clear and simple. The law favours the planning by targets method. Regionalisation: the region is defined as the optimal planning level for initiatives and coordinating the players. Network: the main public healthcare players are assembled around a Public Interest Group (PIG), the Regional Public Healthcare Cluster (Groupement Rgional de Sant Publique, or GRSP). Since then, the Law of 21st July 2009 created the Regional Health Agencies (ARS), which bring together the prerogatives of the GRSP (GRSP) and six other separate departments involved in regional patient care governance under a single authority. Up until then, those departments were managed by the State or the health insurance system.
PLEASE NOTE: A UNIQUE FRENCH CHARACTERISTIC

- There is a culture of consultation and co-operation between healthcare players in France. - Most French people do not dispute the legitimacy of the State on healthcare issues.
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II - Public health care policy

A - A national challenge disseminated at the local level
The aims of public healthcare policy were adopted by national representation, although it was the regional level that was retained to unite the initiatives of the many public healthcare players. At the national level, public healthcare targets are set every five years. The French Government specifies the main action plans that it intends to implement in a report appended to the law. Parliament examines, amends and votes on the law that defines public healthcare targets. At the regional level, the Director General of the Regional Health Agency (ARS) is now responsible for defining and implementing a co-ordinated set of programmes and initiatives for meeting national healthcare policy targets.
B - The States multi-year policy targets

Conscious of the need to plan and assess the policies that it implements, the State has defined national healthcare targets in a report appended to the public healthcare law of August 9th 2004. The aims of public healthcare focus mainly on the results to be achieved in terms of changing the populations state of health or its exposure to a risk factor. There are around 100 of these targets, examples of which include: - Reducing average annual alcohol consumption per inhabitant by 20%; - Reducing smoking rates from 33 to 25% among men and from 26% to 20% among women; - Reducing adult obesity by 20%; - Increasing the number of people who exercise daily for at least 30 minutes, at least five times a week. Meeting public healthcare targets may require defining strategies for action. This work is reflected in the drawing up of plans and programmes.
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C - Public healthcare players in France1

In France, two bodies play a consultative role and assist the Government in drawing up and assessing healthcare policy. The French High Council for Public Health (Haut Conseil de la Sant Publique, or HCSP) The task of the High Council for Public Health, which was founded by the Law of 9th August 2004, is to provide public authorities with the expertise necessary for the management of risks to public health, as well as for designing and assessing policies and healthcare prevention and safety strategies, working together with healthcare agencies. The Council is primarily responsible for assessing whether the public healthcare targets have been met on a five-year basis, as well as for producing a report analysing the populations healthcare problems and the factors likely to have an impact on them, by proposing new quantitative targets. The Council can also be asked to assess some of the major national health plans. The French National Health Conference (Confrence Nationale de Sant, or CNS) A forum for discussion and consultation on healthcare policy exchanges, the Conference contributes to the organisation of public debates and allows players in the healthcare system to express their points of view. The CNS is also a consultation body for the Ministry of Health during the drawing up of the draft law defining public healthcare targets. The Conference prepares an annual report on respect for the rights of those who use the healthcare system, which is addressed to the Minister. The 2009 report, entitled Finalising health democracy and empowering healthcare system users offers recommendations to put the patient at the centre of the healthcare system. The French National Public Health Committee (Comit National de Sant Publique, or CNSP) Public healthcare policy is drawn up at the inter-ministerial level. The Committee coordinates the actions of various ministerial departments in healthcare safety and prevention fields. In terms of prevention, the leading player is the French National Institute for Healthcare Prevention and Education (INPES)
1 - The national network of healthcare agencies is featured in Chapter 7
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The National Institute for Healthcare Prevention and Education (INPES) The National Institute for Healthcare Prevention and Education (INPES)2 is responsible for implementing the healthcare prevention and education policies established by the Government. Its main tasks are: - Implementing prevention programmes; - Playing an expert and advisory role; - Ensuring the development of health education; - Managing emergency situations; - Building a national document network on all subjects relating to health prevention and promotion; - Issuing advice and recommendations: - Participating in European and international initiatives relating to its tasks. The Institute designs and implements a large number of prevention campaigns on major public health priorities. As part of the French Cancer Plan, for example, the INPES launched a campaign to encourage pregnant women not to drink alcohol or smoke. The INPES also conducted prevention campaigns against bird flu and more recently, awareness-raising campaigns on H1N1 flu during the winter of 2009-2010.
Source: INPES website
Health Insurance Beyond its public social protection duties (guaranteeing access to treatment, welfare benefits in the event of medical leave from work, etc.), the health insurance system also plays a
2 - Please refer to Chapter 7 on healthcare agencies
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Source: INPES website

ut National web Instit Source : site
prevention role. The involvement of the health insurance system in this area is the result of an initiative aimed at eradicating certain threats, like infantile obesity, which are likely to weigh on the French healthcare system in the long term, as well as on the social security budget. The health insurance system has the technical skills and the financial resources required to participate in achieving most of the 100 targets set out in the 2004 law. This is why, for example, it runs a vaccination campaign against seasonal flu every year and has organised the Pink October campaign every year since 2004 to remind the public of the importance of breast cancer screening.
du Cancer
The organisation of public health players

ASSESSMENT
Parliamentary assessment office
POLICY
STRATEGY
ACTIONS
Source: Ministry of Health
(High Council of Public Health)
(Expertise) HCSP CNS
(Consultation)
(Fixing targets) Ministry of Health
(Implementation) INPES
Actions (national ou local)
(Coordination) CNSP
(National Public Health Commission)
Ministries Sickness insurance Health agencies Associations
D - Healthcare plans and programmes

Strategic multi-annual plans The Law of August 9th 2004 has designed five national plans regarding: - Cancer Research; - Combating domestic violence, risky behaviours and addictive practices; - Limiting the impact of environmental factors on health; - Improving the quality of life of people suffering from chronic illnesses; - Improving the care provided to people suffering from rare diseases.
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The programmes scheduled by ministerial decree primarily concern prevention and screening programmes. The other plans and programmes implemented since 2001 are ongoing or have been renewed. Around 50 national plans are ongoing. They concern diseases, risk factors, population groups or health warnings. The National Nutrition and Health Programme (Programme National Nutrition Sant, or PNNS) Implementing a nutrition policy has become a public health priority over the past few years. The aim of the PNNS, which was launched in January 2001, is to improve the populations state of health by acting upon one of its main determining factors: nutrition (diet and physical exercise). This programme includes nine priority nutrition targets, focusing on food consumption, exercise or changing biological parameters. The aim is to inform consumers and steer them towards satisfactory food choices, as well as involving food manufacturers and caterers. Among the targets set for 2006-2010, we can mention those that aim to: - Increase consumption of fruit and vegetables; - Increase the amount of daily exercise. Since 2007, a heavy emphasis has been placed on improving the nutritional quality of the foods brought to market. Likewise, another recommendation aims to limit consumption of fats sugar and salt. One of the public campaigns conducted on food consumption therefore recommends eating five portions of fruit and vegetables per day.
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Source: www.mangerbouger.fr - PNNS website

The French National Health and Environment Plan (Plan National Sant Environnement, or PNSE) The PNSE is one of the five multi-year strategic plans drawn up at the national level and enacted by the law on public healthcare policy. The Second National Health and Environment Plan (PNSE2) was published in 2009. Its aim is to prevent diseases that have a major impact on health, to provide better protection to vulnerable population groups, and to reduce geographical environmental inequalities. It therefore covers various priority areas: improving the quality of the atmosphere, indoors and outdoors, and the quality of water, taking account of chemical products and polluted soils, or again, reducing noise black spots and emerging risks. Those in charge have looked for synergies between the National Health and Environment Plan and the National Cancer Plan. The PNSE2 will be implemented in each region through a regional health and environmental plan. In terms of environmental health in their area, each region chooses the appropriate action by taking account of regional health priorities, especially in terms of reducing health inequalities.
Therapeutic Patient Education (TPE): the example of diabetes

Defined as a set of practices aimed at enabling patients to acquire the skills necessary to be proactively responsible for their illness, their treatment and their supervision, Therapeutic Patient Education is primarily aimed at patients suffering from chronic illnesses (20% of the French population): diabetes, asthma, congestive heart failure, etc. These illnesses require daily care and therefore require that patients follow their care programme closely (taking drugs, diet, etc.) Patients are monitored and learn to take responsibility of their illness in partnership with the healthcare staff. As part of this approach, the health insurance scheme has launched a pilot website dedicated to supporting patients suffering from a specific chronic illness: diabetes. The programme has been rolled out over 11 departments and now has 53,000 members. Launched in March 2008, the sophia website offers diabetics a certain number of services for monitoring their illness in a free and effective way: information and practical advice, telephone support provided by healthcare professionals, and a diary to remind them of appointments and check-ups. A recent survey of this support programme has highlighted its effectiveness: better understanding of the disease, encouraging proper monitoring, and progress in terms of a balanced diet. Almost 80% of website members believe that this new patient care model will improve their daily life.
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CHAPTER 7:
Public health agencies
63
CHAPTER 7: Public health agencies

I - A desire to modernise
A new institutional landscape
In France, the creation of independent public bodies first took place as part of a general approach to modernise the State, which goes beyond the health sector. However, from contaminated blood to the mad cow crisis, repeated public health scares in the 1980s and 1990s revealed failings linked to over-centralisation and to a lack of scientific expertise. Moreover, the question of health risks has become a public concern. In 1998, the emergence of the public health doctrine contributed to an overhaul of regulatory methods in the healthcare system. Inspired by Anglo-Saxon or Scandinavian models, public health agencies represent the will to move towards less centralised forms of governance. Commonly known as agencies, they usually have Public Administrative Institution status (Etablissement Public Administratif, or EPA). The agencies, which are in charge of public health assignments, provide monitoring and expert advice in a specific area. Placed under the guardianship of one or several ministries, depending on their remit, they enjoy their own financial resources and independent management. However, the State remains at the controls: it sets the major strategic guidelines, takes the decisions, appoints the directors and checks the agencies results. Reinforcing public health risk expertise and management These organisations are more flexible and responsive in the way that they operate and respond effectively to public health emergencies. Recourse to scientific expertise and distance from the central authorities are proof of their impartiality and credibility. By outsourcing some assignments, the State is freeing itself up from heavy management tasks and reinforcing its prerogatives in terms of public healthcare and public health safety. Moreover, putting in place target agreements clarifies its relationship with the agencies. On the strength of around ten experienced agencies, France has an effective system for guaranteeing public health safety. With important human and financial resources available to them, the agencies are tools to assist with key public healthcare decisions. Working closely with their European counterparts, the French agencies have enjoyed a world-wide reputation for public health expertise and monitoring for several years.
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The National Health Authority1 (HAS) Founded in 2004 as part of the health insurance reform, the HAS goal is to boost the quality of treatment services and to control healthcare expenditure. The HAS, which is responsible for the scientific assessment of the therapeutic benefit of medical products and services, rules on the appropriateness of reimbursing them. The Authority therefore participates in maintaining a socially cohesive patient care system and optimised management of the treatment basket. In order to improve practices and the general quality of the healthcare system, the Authority favours consultation between the players and ensures that the medical information circulated is reliable. It participates in promoting best practices among healthcare professionals and patients by preparing treatment path guides, especially for long-term illnesses like diabetes, asthma or hepatitis C. In terms of treatment safety, the National Health Authority informs the general public about nosocomial infections on a dedicated website (www.infonosocomiale.com).
II - The public health monitoring agency

The French Public Health Monitoring Agency (Institut de Veille Sanitaire, or InVS) Founded in 1998, the INVS carries out monitoring, surveillance and warning assignments in all public healthcare areas. In the event of risks that are likely to have an impact on the populations general state of health, the agency warns and advises the Government about the measures to take to forestall or reduce their impact. Working together with the European Centre for Disease Prevention and Control (ECDC) and as an active member of World Health Organisation (WHO) specialist bodies, the INVS participates in several disease monitoring programmes on a world-wide basis. In a context where public health crises are increasing and becoming global, the INVS has become the preferred technical contact point for several countries. For example, as soon as the first signs of the Severe Acute Respiratory Syndrome (SARS) appeared in May 2003, the Institute rolled out a warning system that enabled a significant outbreak of cases in France to be avoided.
1 - The National Health Authority is not a public health agency, but an independent authority.
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The French Agency for the Public Safety of Healthcare Products (AFSSAPS) Founded in 1999, the AFSSAPS guarantees the quality and safe and proper usage of healthcare products intended for human consumption. On the strength of its multi-disciplinary expertise, the AFSSAPS assesses the risks and benefits of all commercial medical products and services, before allowing them to be marketed. From laboratory controls to inspections of production and testing sites, the AFSSAPS ensures permanent surveillance, in order to assess manufacturing conditions and the data relating to therapeutic systems. In the event that a product has related risks, the Agency can take public health policing measures to safeguard patient safety, like withdrawing a drug. In addition to participating in the drafting of legal and regulatory texts, the AFSSAPS is involved in public healthcare programmes. It makes an active contribution to combating counterfeit drugs within the European Official Medicines Control Laboratories (OMCL) network. The French National Agency for Food Health Safety, the Environment and Labour (Agence Nationale de la Scurit Sanitaire de lAlimentation, de lEnvironnement et du Travail, or ANSES) Founded in 2010, the ANSES is the largest food safety agency in Europe. It took over the assignments, resources and staff of the French Food Health Safety Agency (Agence Franaise de Scurit Sanitaire des Aliments, or AFSSA) and of the French Agency for Environmental and Labour Health Safety (Agence Franaise de Scurit Sanitaire de lEnvironnement et du Travail, or AFSSET). It also took over those agencies goods and values - scientific skills, risk assessment independence, open expertise - in order to apply them to a more global and cross-divisional understanding of public health issues. The French Food Health Safety Agency (AFSSA) The AFSSA, which was founded in 1999 and was operational until 2010, performed a supervisory role in the food field. It assessed public health and nutrition risks throughout the human or animal food manufacturing chain. It was responsible for the warning systems and supported the public authorities in implementing public health protection measures. Moreover, the AFSSA authorised the marketing of veterinary drugs. In addition to promoting the dissemination of scientific knowledge, it conducted research programmes in its eleven laboratories. In 2009, 180,000 tests and diagnoses were performed and the research activities resulted in 250 articles in international reviews. At the European Community level, the AFSSA was involved in drafting the notices issued by the European Food Safety Agency (EFSA).
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The French Agency for Environmental and Labour Health Safety (AFSSET) The AFSSET, which was founded in 2002 and was operational until 2010, assessed inherent health risks in the environmental and labour fields by rolling out several initiatives: scientific monitoring and disseminating knowledge about emerging risks, informing the general public, and contributing to European scientific programmes. By co-operating with specialist industrial and technological bodies, the AFSSET guaranteed a cross-divisional approach to sensitive issues like toxic materials or substances. Its expertise enabled it to issue recommendations for drafting legal and regulatory provisions, as in 2009, on the occasion of the Grenelle Environmental Round Table. The French Institute for Radioprotection and Nuclear Safety (Institut de Radioprotection et de Sret Nuclaire, or IRSN) Founded in 2001, the IRSN is responsible for assessing nuclear and radiological risk. Its expertise extends to complex issues: protection against ion rays, production plant and radioactive matter transportation safety, nuclear expertise for defence, etc. The multi-disciplinarity of its teams - engineers, researchers, doctors, agronomists, veterinarians - enables high-level work to be performed for public or private institutions. As a partner for over 30 countries, the IRNS has acquired international stature. It participates in major research programmes, as well as in the drafting of international recommendations in the nuclear safety and radioprotection fields. The French Bio-Medicine Agency (Agence de la Biomdecine, or ABM) Founded in 2004, the ABM is involved in four medical areas: sampling and transplants, reproduction, embryology and human genetics. The ABM regulates practices and ensures that patient care guidelines are respected: it delivers authorisations for in vitro embryonic research and embryonic stem cell conservation procedures, authorisations for international exchanges for research purposes, and approvals for practitioners and for the opening of specialist institutions. In addition to promoting organ donations, it controls the therapeutic activities linked to transplants - 4,580 organ transplants in 2009 and 4,423 stem cell transplants in 2008. As part of the international campaign against organ trafficking and transplant tourism, the ABM launched an annual anonymous survey for patients who had received transplants abroad, a survey that was copied by several European Union Member Countries.
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The French Blood Transfusion Agency (tablissement Franais du Sang, or EFS) Founded in 2000, the EFS is the sole provider of civilian blood transfusions in France. It guarantees national self-sufficiency in blood products, as well as the safety of the transfusion network. Organised around 17 regional institutions and 9,000 employees, the EFS is responsible for 155 fixed blood collection points and organises 40,000 mobile blood donation centres in France every year. It can therefore supply over 1,900 treatment institutions. The EFS is currently conducting over 50 innovative research programmes with institutes - the National Centre for Scientific Research (CNRS), the National Health and Medical Research Institute (INSERM) - and biotechnology companies. Faced with an increasing need for plasma, the Agency has drawn up a national collection strategy, by putting the emphasis on building donor loyalty. 2007 Report: 6% more donations - i.e. around 1,620,000 more samples and over one million patients cared for. The French Institute for Health Prevention and Education (INPES) Founded in 2002, the INPES implements health prevention and education policies, as well as policies for managing information during health emergencies, like the chikungunya epidemic or the H1N1 flu outbreak during the winter of 2009-2010. It coordinates 12 health promotion programmes through awareness-raising campaigns about alcohol, smoking or sexually transmitted diseases. As a public expert in preventing risky behaviours, the INPES has already been responsible for the publication of over 70 million information documents. Some of its studies, like the Health Barometers are now benchmark indicators for changing behaviours in terms of health. In addition to participating in the management and funding of local prevention players, the INPES co-ordinates the HPH - Health Promoting Hospital - network created by the WHO.
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The French Organisation in Charge of Preparing for and Responding to Public Health Emergencies (tablissement de Prparation et de Rponses aux Urgences Sanitaires, or EPRUS).
Since 2007, the EPRUS responds to large-scale public health emergencies. In the event of a public health alert and the overloading of the French healthcare system, the EPRUS can mobilise human and logistical resources quickly, in France and abroad. It is responsible for the use of previously untried tools: the public health reserve corps - the intervention of volunteer healthcare professionals - and the national healthcare stock (managing healthcare product reserves and logistics). In order to respond to recent flu pandemic threats, the EPRUS is currently managing stocks or around 1.5 billion face masks and 70 million doses of Tamiflu. At the very heart of the national public health safety system, the EPRUS benefits from a network of competent participants in crisis situations: Civil security and the army healthcare service, specialist associations like the Red Cross, healthcare professionals and Non-Governmental Organisations (NGOs) like Mdecins sans Frontires. The EPRUS also aims to intervene abroad: for example, it sent around 15 volunteer doctors to Gaza in 2009.
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CHAPTER 8:
Health insurance
Financial risks linked to illness, workplace accidents and professional illnesses are mostly insured by the health branch of the social security system: the health insurance system. Top-up organisations, mutual benefit and private insurance funds, and the French Universal Healthcare Coverage System (CMU) provide guaranteed top-up insurance to around 95% of the population. Compulsory health insurance covers over 75% of healthcare expenditure (services amounting to 130 billion).
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CHAPTER 8: Health insurance

Health insurance, which is responsible for the health branch, is based on three founding principles: equality of access to treatment, social solidarity and quality of treatment. It has gradually been extended to all socio-professional categories and to the most deprived population groups, through the creation of Universal Health Care Coverage in 2000, from which 4.3 people now benefit. In addition, coverage for people insured by the social security system extends to their beneficiaries, i.e. their spouse and children, in principle up to the age of 16. Almost the entire French population benefits from health insurance coverage, based on their employment, family ties or on socio-economic criteria. The various social security schemes, which are under State control, participate in implementing the compulsory health insurance system. The general social security scheme, managed by the National Health Insurance Fund for Salaried Workers (CNAMTS), covers over 89% of the population; The Agricultural Workers and Farmers Mutual Benefit Fund (MSA) covers around 5,4% of the population; The Social Security Scheme for the Self-Employed (RSI) covers around 5,4% of the population. The various special schemes cover health and professional risks for specific professional classes.
I - Personal health coverage

A - Health coverage, accidents in the workplace and professional illnesses
Health insurance represents 30% of personal insurance expenditure in France. Health coverage takes different forms according to the nature of the risk and the nature of the treatment. It also provides maternity leave coverage. Reimbursement of the costs: out-patient and hospital treatment Reimbursement for treatment expenses are part of a triangular relationship: the patient pays the medical expenses in advance, the healthcare professional receives his fee at the end of the appointment and the health insurance fund that insures the patient reimburses him at a variable rate. In principle, health insurance only funds corrective treatments and certain preventive actions, like vaccinations, directly. That funding is carried out in the
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form of services in kind (repayment of the expenses incurred); however, the direct payment mechanism is gradually being extended to out-patient treatments and avoids the patient having to pay the expenses incurred in advance. The cost of medical procedures - fees, cost of services and healthcare products - corresponds to the statutory rates negotiated between the insurance fund and the healthcare professionals unions. For healthcare products (drugs), the reimbursement rate varies according to how the medical service performed is recognised in products and services and to the negotiations between the various players involved in the supply and refunding of medical expenses. The services in kind covered by the health insurance system mainly involve: General and specialised medical costs, together with surgical costs; Spending on pharmaceutical products, like drugs and some contraceptives, appliances and prostheses Examinations and tests required for medical diagnosis or to determine the dosage of a drug; Admission to hospital and treatment at health resorts (follow-up and rehabilitation treatment) The cost of medical transport in the event of accidents, serious illness or disability. The medical procedures reimbursed, in whole or in part, by the health insurance system, are featured on lists that define their content. The common classification of medical procedures classifies over 7,500 technical, medical and surgical procedures in this way, according to a single scale that is valid for out-patient and hospital treatments. It acts as a benchmark to set the reimbursement rate for different services. The co-payment portion determines the portion that is left up to persons insured by social security, in order to make them responsible for their treatment use and involve them in balancing the health insurance systems books. The same goes for the daily flat-rate hospital payment for short or medium-term stays in hospital (18.00 in a hospital or clinic, 13.50 in psychiatric departments). Several groups are, however, exempt from the flat-rate payment: pregnant women, beneficiaries of Universal Medical Coverage, victims of workplace accidents, etc. Along the same lines, the medical excess payment system determines a flat-fee payable by the insured person, which varies according to the medical products and services used: 1.00 per out-patient procedure or appointment, 0.50 per packet of drugs, 2.00 for an ambulance journey. The annual ceiling for these flat-rate charges is set at 50.00 per insured person and some social groups are exempt from flat-fees and the co-payment portion (Universal Healthcare Coverage beneficiaries). Finally, certain procedures require prior agreement from the health insurance system (prior understanding) for certain innovative or costly procedures like fitting prostheses.
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Welfare benefits Workplace accidents and professional illnesses are covered by the health arm of the welfare, system in the form of daily compensation payments. As long as they have a medical leave of absence certificate signed by a doctor, the person insured, the patient or the accident victim receive a benefit, paid by the primary health insurance fund (CPAM), from the fourth day of the prescribed leave period. The three unpaid days are scheduled to avoid abuse of absenteeism without good reason. The primary insurance fund is informed of the employees leave of absence through the forwarding of the doctors certificate. The additional payment is paid by the company or the welfare organisation that the insured person belongs to (10 unpaid days). The benefit guarantees 90% of an individuals daily remuneration. The amount of the indemnities is reassessed according to the length of the absence, to the number of dependent children and the nature of the disease. In the event of long-term illness, the payments may be made for a period of three years. Maternity and paternity leave As persons covered by social security or beneficiaries thereof, pregnant women are fully reimbursed for medical expenses arising from their pregnancy. Salaried women benefit from benefits and basic maternity leave for sixteen weeks. That period varies depending on the number of children who are already dependent or who will be born at delivery, with a maximum compensation period of 34 weeks (except in case of complications). The amount of the indemnity corresponds to the daily basic salary, with a ceiling set at 75.00 per day, on average. Some collective agreements provide for the full salary to be paid by the company during maternity leave. Likewise, since 2002 paternity leave has enabled fathers in employment to receive compensation for between 11 and 18 days, depending on the case. Invalidity Following an illness or an accident outside work, an insured person who is under 60 may benefit from an invalidity pension, in order to compensate for their potential physical and mental disabilities at work. There are a number of categories, depending on the level of handicap, and the amount of compensation varies between 260 and 2,500 per month.
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B - Reform of the health insurance system.

The aim of the law of August 13th 2004 on health insurance is more efficient risk management, through renewing governance methods. On the strength of its wider remit, health insurance is now positioned at the heart of the healthcare system and plays a fundamental role in public healthcare policy consistency. As it is associated with the drawing up of hospital and drugs policy, the health insurance system has seen itself awarded new prerogatives in terms of out-patient treatment. Health insurance funds are involved in the management and supervision of healthcare expenditure, with the aim of co-ordinating treatment and the medical management of healthcare expenditure. The new remit awarded to the health insurance system has resulted in a reorganisation of its governance and greater clarity in the mutual responsibilities of the players involved. They must all co-ordinate their actions in the aim of achieving medical management of public healthcare expenditure.
FOCUS:Better treatment at a lower cost!

Medical management aims to promote the quality of treatment while encouraging better use of public resources in terms of healthcare expenditure, in order to achieve an efficient and socially cohesive healthcare system on a durable basis. Without jeopardising quality or safety, medical management looks for productivity gains within the treatment system, by primarily insisting on the effectiveness of recourse to treatment and on the coordination of treatment and healthcare professionals. This approach is based on a strong partnership between the health insurance system, healthcare professionals and treatment institutions. It also aims to develop effective cross-divisional patient care between the outpatient, hospital and medico-welfare sectors. Finally, it demands a taking of responsibility in the use and prescription of treatments. The various players undertake to participate in implementing the co-ordinated treatment path with the attending doctor, to rationalise medical drug prescriptions by favouring generic drugs, to strengthen checks on absences from work and to monitor patients with long-term conditions or even to roll out in-home hospital services.
The State guarantees the effectiveness and the fairness of the healthcare and compulsory health insurance systems and always set the main public health targets and the multi-
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year conditions for balancing the books of the various social security schemes. It also ensures the quality of and equality of access to treatment throughout France, as well as the fairness of the patient care provided by the various social security schemes. Today, the regional unit is recognised as the level of reference for managing public healthcare policy. Every year, Parliament votes on the Social Security Funding Bill (LFSS), which sets the annual health insurance spending targets (ONDAM) for all the schemes. As part of the draft 2009 social security funding law, the 2010 targets for health insurance spending were set at 162.4 billion, i.e. an increase of 3% compared with 2008 (157.9 billion).
The National Union of Health Insurance Funds (UNCAM) and the National Union of Top-Up Health Insurance Organisations (UNOCAM)
Since 2004, the health insurance funds of the three main schemes have been combined in a single entity. The UNCAM is responsible for the coordination of these funds and plays a central role in managing health insurance. It negotiates and finalises national agreements and covenants with healthcare professionals. Relying on the opinions issued by the National Health Authority (HAS), the UNCAM classifies drugs according to their therapeutic usage and sets the reimbursement rate for treatments within the limits of the annual health spending targets. In so doing, it determines the healthcare procedures approved for reimbursement. Finally, the UNCAM plays a consulting role and gives its opinion on draft laws and other regulatory texts. Meanwhile, the National Union of TopUp Health Insurance Organisations (UNOCAM) brings together all the mutual top-up organisations governed by the Mutual Organisations Code as well as welfare institutions and insurance companies governed by the Insurance Code. The UNOCAM issues opinions on decisions taken by the UNCAM that have an impact on the expenditure of top-up health insurance organisations, like the admissibility of and the reimbursement rate for healthcare procedures and products or the terms of the national covenants agreed with healthcare professionals. Moreover, the National Union of Healthcare Professionals (UNPS) negotiates with the UNCAM and the UNOCAM when these covenants are drawn up. The synergies between the health insurance system, top-up insurance bodies and healthcare professionals contribute to a consistent management of the treatment system.
Other entities are also involved in managing and regulating the compulsory health insurance system at the national level. The Economic Committee for Healthcare Products (CEPS) helps draw up the drugs policy; The Institute of Health Data makes sure that the information systems for managing health risks are consistent and high-quality;
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The National Health Authority (HAS) - an independent public authority with a scientific remit - takes care of improving healthcare quality. In terms of healthcare services and products, it assesses the medical benefit of all the medical procedures reimbursed by the health insurance system and issues opinions for the intention of the UNCAM on whether their reimbursement is justified or not. In terms of treatment quality and safety the HAS promotes the exchange of best professional practices and medical information for out-patient and hospital treatments alike. Finally, it draws up certification procedures for treatment institutions and assessment procedures, and encourages the computerisation of medical data. The Warning Committee for Health Insurance Expenditure warns Parliament and the Government, as well as health insurance funds, if there is a risk of the annual health insurance spending targets being exceeded. The Hospital Admission Council is involved in defining the funding procedures for treatment institutions and in measures to manage hospital expenditure. National level
The ARS national steering committee examines national risk management programmes
Contract between the State and Uncam Targets and management contract (COG) Regional health agency (ARS) Multi-year risk management programme
National actions defined by the contract between the State and Uncam Additional actions to take account of specific regional factors
Regional level
The ARS defines the multi-year risk management programme (risk management decree)
Contract between ARS and Cpam (Sickness Insurance

Office) in the framework of the regional health project
Multi-year management programme (CPG)
Sickness Insurance Office (CPAM)
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II - The different welfare schemes

A - The general scheme: health insurance
As a decentralised public service, the general scheme is organised according to three area levels and structures as a vast health insurance fund network. At the national level The National Health Insurance Fund for Salaried Workers (CNAMTS) manages two separate risks: Health, which includes illness, maternity, disability and death; Workplace accidents, which includes accidents and professional illnesses. Its director is also responsible for the UNCAM. In addition to managing the administration of the UNCAM, the CNAMTS co-ordinates the regional and local funds. It also manages the national medical service, which has an expert remit that primarily consists in checking the medical justification for the treatment prescribed and used, with the aim of supporting medical management of healthcare expenditure. As part of the CNAMTS, this checking service is assigned to advisory practitioners at the local level. Every year, those practitioners hold meetings with their colleagues regarding good therapeutic and prescription practices, and raise their awareness about medical management of expenditure. Over 40,000 meetings were held between 2006 and 2008. At the regional and local level The creation of local health agencies introduced several major changes at the local level. The Regional Health Agencies (ARS) receive part of the allocations granted to the Regional Health Insurance Funds (Caisses Rgionale dAssurance Maladie, or CRAM), which became Retirement and Health in the Workplace Insurance Funds (Caisses dAssurance Retraite et de la Sant au Travail, or CARSAT) during 2010. The Regional Health Agencies (ARS) took over the health arm of the CRAM, while the pension and health in the workplace insurance funds kept their remit in the retirement and professional risk insurance fields. There are 16 CARSATs in metropolitan France, which are involved in defining and applying regional public health and social security guidelines, as well as guidelines on accidents at work, professional illnesses, old age and retirement (except for the Ile-de-France and Alsace-Moselle insurance funds, which have no old age remit). They fund the systems that promote quality of life and
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treatment for the elderly and the disabled. The CARSATs also play an important role in terms of health and safety at work by implementing policies for preventing professional risks. At the local level, Primary Health Insurance Funds (CPAM), ensure local relationships between insured persons and the health insurance system. In order to carry out day-today transactions like registering insured persons or reimbursing services, the CPAM fund and carry out prevention and health promotion initiatives. Those initiatives can now be conducted in relation with the Regional Health Agencies (ARS) in accordance with the regional health plan. Every department has at least one CPAM. There are currently 101 CPAMs in metropolitan France. In the French overseas departments, the four General Social Security Funds (Caisses Gnrales de Scurit Sociale, or CGSS) play the combined role of a CPAM, a family welfare fund and of an Association for Gathering Social Security and Family Benefit Contributions (Union pour le Recouvrement des Cotisations de Scurit Sociale et dAllocations Familiales, or URSSAF).
Service for patients and professionals

Thanks to the computerisation of claim forms made possible by the Carte Vitale, expenses are reimbursed within five days, compared with 12 days for traditional claim forms. The 5,500 drop-in centres in metropolitan France welcome 40 million insured persons every year and handle 20 million telephone calls. Since January 2007, a call centre has been informing insured persons about their rights, the rates in force or the details of practitioners close to their home. According to daily summary updates of the Carte Vitale, over 75,000 transactions are performed every day at the 1,100 automatic health insurance counters. Insured persons can set up a personal account on the ameli.fr website, in order to monitor their reimbursements, fill in administrative forms on line and gain access to lists of rates and addresses for healthcare professionals and treatment institutions. Healthcare professionals can consult their payments and the list of patients who have chosen them as their attending doctor through a personal online account, or order the prevention campaign materials that are made available to them. Finally, companies can perform all their administrative tasks (social security statements, salary declarations) on line thanks to the net-entreprises.fr remote service. They can also subscribe to the services provided by the risquesprofessionnels.ameli.fr website to keep themselves informed and follow the compensation paid to their employees who are on medical leave from work.
Founded in 2000, the 13 Health Insurance Fund Managers Unions (Unions des Gestionnaires des Etablissements des Caisses dAssurance Maladie, or UGECAM) manage
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a network of 150 medical and medico-social institutions that are part of the health insurance system and ensure the quality of those services at the level of their own region. Regional Health Agencies (ARS) work together with the regional representatives of health insurance bodies to draw up a multi-year regional risk management programme that includes the risk management actions and targets defined at the national level in the contract between the State and the UNCAM. This multi-year programme also includes additional (regional) initiatives and targets linked to local particularities.
KEY NUMBERS
The national target for the general schemes (metropolitan France and French Overseas Territories) 2009 health insurance expenditure amounted to 150.8 million for the health branch and to 173.8 billion for the schemes overall. The health insurance branch accounted for revenues of 162.3 billion in 2009. The expenditure target for the workplace accidents and professional illnesses branch was 11.2 billion for the general scheme. The revenues of the workplace accidents and professional illnesses branch amounted to 12.1 billion.
RESULTS ACCOUNTS AND STATEMENTS
THE SICKNESS BRANCH
COSTS
ORGANISATION
166,125
million euros
Non-hospital health care: 31 % Care in establishments: 41 % Daily benefits: 5 % Other benefits: 3 % Other technical costs: 16 % Day-to-day management costs: 4 %
PRODUCTS
ORGANISATION
161,676
million euros
Contributions: 44 % General Social Contribution: 32 % Taxes allocated: 9 % Other products: 15 %
BALANCE COSTS
ORGANISATION
2001 -2 046 M
2002 -6 124 M
2003 -11 064 M
2004 -11 642 M
2005 -8 009 M
2006 -5 934 M
2007 -4 629 M
2008 -4 449 M
- 4 449 M
THE AT/MP BRANCH
11,068
million euros
Non-hospital health care: 5 % Care in establishments: 5 % Permanent incapacity: 36 % Daily benefits: 20 % Other services: 2 % Other technical costs: 25 % Day-to-day management costs: 7 %
PRODUCTS
ORGANISATION
11,309
million euros
Contributions: 74 % Taxes allocated: 18 % Other products: 8 %
CNAMTS ACTIVITY REPORT 2008
BALANCE
2001 20 M
2002 -45 M
2003 -472 M
2004 -184 M
2005 -438 M
2006 -59 M
2007 -455 M
2008 241 M
241 M
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The health insurance system handles over a billion reimbursement requests per annum. The expenditure breaks down as follows: sickness (118.8 billion), maternity (5.98 billion), disability (4.43 billion) and death (161 million). Sickness and maternity benefits therefore account for 85% of the health insurance arms expenditure. Medical management enabled savings of 495 million to be made in 2008. From 2005 to 2008, the anti-fraud and abuse campaign has enabled savings of 358.2 million.
B - The Social Security Scheme for the Self-Employed (RSI)

Founded in 2006, the RSI covers sickness, maternity and old age insurance for all self-employed professions that are described as nonsalaried and non-agricultural. The RSI combines all the management bodies involved in covering the self-employed and has been the sole point of contact in relation to the social security payments and contributions made by business owners who are craftsmen, manufacturers or retailers, since 2008. From that point, the RSI became responsible for the payments that were previously managed by different bodies and in so doing, was involved in making the reimbursement system clearer for its members. Beyond its welfare remit, the RSI provides personalised support for the self-employed in the steps that they take in relation to their health, and occasionally to their retirement, at decisive moments in their career path, as well as their private life. The local organisation is similar to the health insurance organisation: a national fund under the States guardianship, a network of around thirty inter-professional regional funds and two funds dedicated to professional occupations (for health and maternity coverage). In addition to a large number of local drop-in centres, the RSI has created a network of approved bodies throughout France in order to fulfil health insurance and maternity payment reimbursement assignments effectively. In terms of prevention, the RSI disseminates national prevention initiatives and conducts several initiatives in the screening (breast, uterine and colon cancer), addiction, vaccination and screening (hereditary and professional illnesses) fields
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KEY NUMBERS 2009

DEMOGRAPHICS 2,1 millions paying members, 3.5 million health insurance beneficiaries, 22 000 disabled members EXPENDITURE 6.6 billion on healthcare reimbursements (3,2 billion for out-patient care, 3.4 billion for treatment institutions, 209 million for daily compensation payments)
Population protected by RSI sickness insurance in 2009
643,252 Pensioners
19%
0,17%
Free
51,83%
1,012291 Beneficiaries
29%
1,793539 Active and Active Retired
C - The Agricultural Workers and Farmers Mutual Fund (MSA)

The Agricultural Workers and Farmers Mutual Fund (MSA) manages the overall farmers welfare scheme (healthcare, retirement, family benefits, etc.) for farmers, employees, employers of agricultural labourers and their families, i.e. over six million beneficiaries. The MSA network, which consists of a central fund and 35 multi-departmental funds, therefore pays out over 27.1 billion in reimbursements every year. In addition, it gathers and checks the social security contributions payable by farmers and employers of agricultural labourers. At the healthcare level, guaranteeing a treatment provision that is accessible to everyone in rural areas represents one of the MSAs priorities. Faced with the very unequal distribution of healthcare professionals in France, with transport issues with an aging population, the
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Source: RSI Annual Report 2009 and RSI in figures 2009
5,817

MSA offers innovative services and patient care methods that are innovative and based on experimentation: supporting the creation of rural multi-disciplinary health centres and contributing to the development of gerontology networks to keep the elderly in their own homes. Prevention has also been a priority intervention area for many years and is intended for all audiences (bucco-dental examinations, Aging Well workshops, and memory boosting sessions). Moreover, the MSA is the only welfare scheme that directly associates occupational medicine and the prevention of professional risks in its area of activity.
KEY NUMBERS 2009

DMOGRAPHIE 1.2 million active members, 200 000 employers, 3.5 million people with health insurance coverage, 2.3 million people insured against accidents in the workplace, 3.9 million beneficiaries of public health and social security initiatives (insecurity, disability, gerontology, public health prevention, families and young people) FUNDING 27.7 billion for the agricultural schemes welfare services in 2009 (metropolitan France and French Overseas Territories), 40% of which was spent on health insurance coverage
Population protected by MSA sickness insurance in 2009

277,045 spouses
596,987 children and other beneficiaries
16,9%
2,667,079 insured persons (active and non-active) i.e. 75% 874,032 beneficiaries (children and spouses) i.e. 25%
1,536810
non-active
43,4%
1,130269 active persons
31,9%
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Source: MSA activity report 2009
7,8%
STATE
Scientific assessment K Issues recommendations on reimbursements Establishes medical frames of reference Informs all players
coordinate reimburse delegate
HIGH AUTHORITY FOR HEALTH

Fund (employees)
CNAMTS French National Health Insurance MSA French social security agency
for agricultural wage earners and non-wage earners (farmers)
Fixes health strategy and conditions for multi-year equilibrium of social systems
RSI Social System for Independents
Guarantees satisfactory operation of the system
(self-employed) Propose and manage budgets for their system
UNCAM
National Union of Sickness Insurance Offices Proposes the list of procedures accepted for reimbursement
HOSPITALISATION COMMITTEE THE PATIENT

provide care
Participates in pricing decisions
coordinate
provide care
negotiate
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soignent provide care reimburse
HOSPITALS
Can vary reimbursement rates within limits defined by the State Negotiates with health care professionals
coordinate coordinate
HEALTH PRODUCTS ECONOMICS COMMITTEE
Local Sickness Insurance Network
UNOC
National union of top-up organisations
negotiate Issues opinions on certain decisions and proposals from UNCAM Participates in negotiations between UNCAM and health care professionals
Participates in political decisions on drugs
HEALTH CARE PROFESSIONALS
DRUGS
Main structures of the new management Management structures Health care institutions
CPAM Local Sickness Insurance Fund URCAM Regional Union of Sickness Insurance Offices Other basic offices for self-employed workers (agricultural and non-agricultural)
CHAPTER 9:
Top-up health insurance schemes and access to treatment for all

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CHAPTER 9: Top-up health insurance schemes and access to treatment for all
I - Treatment access systems

A - The health insurance top-up scheme: an essential safeguard
If we consider the financial contribution represented by the co-payment portion, compulsory health insurance may turn out to be inadequate for healthcare expenditure reimbursements. The benefit of a top-up health insurance scheme is therefore often required so that patients are not left with expenses that they cannot meet. Indeed, the lack of top-up coverage is an important factor for not seeking treatment: 32% of people who are not covered have stated that they have not sought treatment for certain conditions. Compulsory health insurance Membership Compulsory Top-up health insurance Optional (except in the case of collective agreements) 93% of the population, including 8% covered by the CMU and 4% covered by the CMU-C. Flat-rate Funds 13 % of current expenditure on medical treatment and goods
Cover Funding Share of funding
The whole population According to income Funds 78% of current expenditure on medical treatment and goods
B- Public systems aimed at improving access to treatment

The Law of July 27th 1999 on the creation of Universal Healthcare Coverage (CMU) filled the gaps in the system by offering the most disadvantaged members of society access to free health insurance services and free top-up health insurance. This system consists of two parts: basic Universal Healthcare Coverage (CMU) and Universal Top-Up Healthcare Coverage (Couverture Maladie Universelle, or CMU-C).
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The basic CMU The CMU requires that any person who is not covered by another health insurance scheme joins the general health insurance scheme. The basic CMU enables the beneficiary to enjoy all the services in kind (reimbursements) provided by health insurance. It gives rise to the same rights and obligations as the latter: the beneficiary is liable for co-payment and for the flat-rate hospital fee, i.e. the part that is not covered by health insurance. In principle, the beneficiary pays for his doctors appointments and for his drugs at the chemists and is reimbursed by his health insurance fund on the same basis as other social security beneficiaries. Universal Top-Up Healthcare Coverage (CMU Complmentaire, or CMU-C) CMU-C enables free top-up health insurance to be provided on a means-tested basis: the applicants annual income must not exceed a certain ceiling, which varies according to the make-up of the household ( 7,521 for a single person in metropolitan France in 2009). Beneficiaries have the right to full reimbursement of their co-payments and flat-rate hospital fees, as well as to any payments over and above the standard charges for dental care, eye care and some medical equipment (hearing aids, appliances, etc.) These services therefore offer the possibility of accessing the full healthcare system at no cost and without any advance payment, as the beneficiary is automatically entitled to direct payment Assistance with Purchasing Top-Up Insurance Policy (Aide lAcquisition dune Complmentaire Sant, or ACS) The Law of August 13th 2004 completed the Law of July 27th 1999 by introducing Assistance with Purchasing Top-Up Insurance Policy, for the benefit of people whose income is slightly above the CMU-C cut-off point. The ACS comes in the form of financial assistance with the payment of an individual health insurance policy. If the households income falls in a range between the CMU-C ceiling and the CMU-C ceiling plus 20%, the health insurance fund provides a certificate that gives the holder right to an ACS. The amount of that assistance varies depending on the age of the beneficiaries: 200 for those aged between 16 and 25 and for those aged between 25 and 59, and 400 euros for those aged over 60. The ACS grants the right to: - A cheque-certificate that can be presented to the top-up health insurance fund that is freely chosen by the beneficiary (health insurance fund, mutual benefit fund or insurance company);
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- Dispensation from paying the portion covered by the health insurance system for doctors appointments, within the context of the co-ordinated treatment plan. The CMU Fund When it was launched by the Law of July 27th 1999, the CMU Fund covered the funding of CMU-C; it began covering the expenses of the ACS from 2004 onwards, thanks to various public contributions. Since the 2009 Social Security Funding Law, the CMU Fund now has a proprietary funding resource: the top-up insurance organisations tax, which has risen from 2.5% to 5.9%. The health insurance allocation that was supposed to fund assistance with top-up health insurance has been abolished and the funding is now the responsibility of the CMU. Funding for the CMU-C and the ACS amounts to around 1.7 billion per year. State Medical Assistance State Medical Assistance (Aide Mdicale de ltat, or AME) is intended to cover the healthcare expenses of peoples who do not meet the stability and residence conditions required to benefit from the CMU. In other words, the AME is intended for illegal immigrants who do not have any social security coverage, on condition that they have been resident in France for over three months. AME beneficiaries are not required to pay any hospital or out-patient fees in advance.
II - Private top-up health insurance schemes

In addition to interventions by social security and the State, the organisations that have been authorised to offer top-up health insurance include mutual benefit funds, welfare institutions and insurance companies. Top-up insurance policies can be taken out on an individual basis or as part of a company contract, with funding from the employer. In that case, they are compulsory for all the employees involved. There are also policies for insuring specific groups, like student policies. Top-up health insurance schemes offer basic insurance that covers the co-payment portion that is not covered by the compulsory health insurance scheme, or more extensive services: medical or surgical hospital expenses, the flat-rate daily hospital fee, doctors appointments, drug costs, opticians expenses etc.
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A- Not-for-profit organisations
Mutual benefit funds The mutual benefit fund sector represents 86% of top-up insurance organisations and brings together over 2,000 mutual benefit funds and mutual benefit funds associations. These institutions, which were originally governed by the 1898 Mutual Insurance Charter, continue to operate according to the principle of involving policyholders in their management. They do not discriminate on grounds of an individuals state of health. Mutual benefit funds finance top-up social security coverage, as well as welfare initiatives (old age, disability and death) through subscriptions, the amount of which does not depend on the individual characteristics of the members. In addition to these insurance services, they manage over a thousand different social associations and institutions for their members (hospital institutions, retirement homes, leisure centres, dental practices, etc.) The French Mutual Insurance Sector is campaigning for direct payment, a mechanism that enables its members not to pay medical expenses in advance. Those expenses are covered by the mutual benefit funds within the context of agreements signed with social security, healthcare professionals and treatment institutions. Welfare institutions Welfare institutions are also private not-for-profit organisations. They manage collective personal insurance policies, i.e. policies within the exclusive context of a company or a professional sector. The Board of Directors is made up of equal numbers of employee and employer representatives. It is responsible for implementing guarantees for the exclusive benefit of the employees. These institutions are also involved in other insurance fields: retirement, life, incapacity or disability insurance.
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B - The operators
Insurance companies Insurance companies account for over 10% of top-up insurance organizations. Unlike the two previous categories, they are profit-making organisations. Reimbursement guarantees vary according to the policies: coverage of just the co-payment portion, full or partial reimbursement of the expenses that remain the policy holders responsibility (above the standard rates).
UNOCAM
The Law of August 13th 2004 created the National Union1 of Top-Up Health Insurance Organisations (UNOCAM), which includes the three categories of institutions concerned. Its main aim is to improve co-ordination between compulsory health insurance and top-up health insurance systems, in order to define a risk management policy that can be shared by all players in the healthcare system.
1 - See chapter 8 on health insurance N 701, septembre 2009, les Comptes nationaux de la sant en 2008, Annie Fenina, Marie-Anne Le Garrec et Michel Due, DREES
Expenditure on medical treatment and funding structure Social security1 CMU-C basic organisation and AME Top-up organisations2 Mutual insurance funds2 Insurance companies2 Welfare institutions2 Households Total
(1) (2)
1995 77,1 1,1 12,2 7,3 3,3 1,6 9,6 100,0
2000 77,1 1,2 12,8 7,7 2,7 2,4 9,0 100,0
2004 77,1 1,4 13,2 7,6 3,1 2,6 8,3 100,0
2005 77,0 1,3 13,2 7,7 3,1 2,5 8,4 100,0
2006 76,3 1,4 13,4 7,8 3,2 2,4 8,9 100,0
2007 76,1 1,4 13,5 7,7 3,3 2,5 9,0 100,0
2008 75,5 1,3 13,7 7,7 3,5 2,5 9,4 100,0
: y compris les dficits des hpitaux publics : y compris prestations CMU-C verss par ces organismes
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CHAPTER 10:
Healthcare expenditure and funding the provision of treatment
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CHAPTER 10: Healthcare expenditure and funding the provision of treatment

I - Expenditure
Every year, the national healthcare accounts identify all the expenditure incurred in the public health and medico-social fields. They also enable an understanding of the distribution of financial contributions between the State, local authorities, the health insurance system, top-up health insurance organisations (mutual benefit funds and welfare institutions) and households. We can identify: The Consumption of Medical Treatments and Goods (Consommation de Soins et de Biens Mdicaux, or CSBM): this includes treatments in hospitals and in the medicalised sections of retirement homes (the elderly) out-patient and preventive medicine treatments, and medical transportation and products; Day-to-day healthcare expenditure: this covers a wider range of expenditure than the CSBM. Indeed, it extends to daily compensation payments (leave of absence from work), to subsidies received by the healthcare system and to the cost of managing the public health administration, as well as to expenditure on medical prevention, research and training.
NEWS UPDATE: THE 2008 NATIONAL HEALTHCARE ACCOUNTS

In 2008, the CSBM reached 170.5 billion (8.7% of GDP) and day-to-day expenditure stabilised at 215 billion (11% of GDP). Thanks to the measures taken over the past few years to promote medical management of treatments, the increase in healthcare expenditure has slowed, particularly for some public health products and services (medical assistants, medical transportation and drugs). The excess payments that were put in place in 2008 brought in income of 890 million. The use of generic drugs continues to increase and they represented 11% of sales in 2009, i.e. a saving of around 1 billion for the health insurance system. Healthcare expenditure was funded by public and private sources. The portion of the CSBM funded by social security amounted to 75.5%. The contribution from top-up organisations continued to increase, reaching 13.7% and, finally, the payments for which households were responsible amounted to 9.4% of the CSBM.
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The treatment basket

Healthcare products and services that are covered by the health insurance system and top-up organisations are featured on lists detailing their rates and the basis for regulatory reimbursement. There are several lists of medical procedures and goods, accessible via a dedicated internet website: The list of procedures and services breaks down in turn into two categories: The General Classification of Professional Procedures (Nomenclature Gnrale des Actes Professionnels, or NGAP): this classification applies to clinical medical procedures and to procedures performed by dental-surgeons, midwives and medical assistants. The Common Classification of Medical Procedures (Classification Commune des Actes Mdicaux, or CCAM): this classification applies to specialist procedures carried out in the private sector and in the public and private hospital sector. It identifies coded procedures by describing the techniques of different medical specialisations and their cost. It serves as the basis for rates covering fair payment for private practice procedures and the allocation of hospital resources. The national table of biology codes (Table Nationale de Codage de Biologie, or TNB): this list identifies the applicable rates for tests, examinations and other expenses linked to services performed in laboratories. The list of reimbursable proprietary drugs: it determines the medical products and services reimbursed by the health insurance system and the statutory rate for drugs negotiated with the pharmaceutical laboratories. The list of products and services for medical procedures: this list focuses on the procedures used for quality-of-life treatments and equipment, dietary products, bandages, prostheses and other procedures for the physically disabled.
II - Funding the healthcare system

In accordance with the separate risk principle, the financial organisation of the general insurance scheme is based on the independence of the various welfare branches (illness and workplace accidents, family and old age). Each branch has its own budget and each
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national insurance fund is responsible for balancing its branchs books. Unlike State and other public authority resources, the welfare system complies with the principle of income and expenditure allocation: contributions from employees and employers are clearly identified and allocated to the corresponding branch. In addition to ensuring the clarity and transparency of funding, this method of allocating subscriptions enables the income and expenditure linked to a specific social risk to be directly associated. The French Parliament has voted on the Social Security Funding Bill (LFSS), which has set the annual targets for health insurance expenditure (ONDAM) for all compulsory health insurance schemes, since 1997. Out of concern for balancing the books of the social security system, the ONDAM rely on changes in the previous years expenditure, in the populations needs and in the resources available. The targets are indicative without being restrictive and break down into six areas of expenditure that each correspond to a given category: Out-patient treatments, which correspond to the fees charged by private medical practitioners: 75 billion in 2010; Treatment institutions funded by the T2A: 52 billion; Other healthcare institution expenditure: 19 billion; Alternative patient care methods: 1 billion; Subsidies paid to institutions and services for the elderly (7 billion) and the disabled (7.9 billion).
Structure of the health insurance systems income

The way the health insurance system is funded is essentially based on social security contributions levied on employment income. Since the 1990s, the sources of income have become increasingly diversified with the transfer of levies and taxes to the health insurance branch and especially with the introduction of the General Social Security Contribution (Contribution Sociale Gnralise, or CSG). Contributions: in the aim of sharing the cost of funding the social security system, there are two kinds of contributions: employer contributions at a rate of 12.80% and employee contributions (0.75%). The latter have virtually disappeared following the introduction of the CSG. In 2008, contributions represented 49% of the health insurance branchs resources.
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The CSG: the proceeds of this tax, which were introduced in 1991, are specifically intended for the social security system. In addition to income from employment and payments in lieu, the tax changes the funding structure of the social security system by extending the levy to income from investments and capital. The CSG rate amounts to 7.5% except for welfare benefits (6.2%). Health insurance schemes benefit from around 70% of the proceeds. Tax receipts: taxes and levies assigned to funding the health insurance branch, like those on alcohol, tobacco, cars and drugs. The various schemes are linked by a balancing mechanism in order to compensate for their diverging demographic trends. Finally, the State also makes a contribution, in the form of balancing subsidies for schemes with a deficit and invalidity payments. Simplified structure of the health insurance branch funding in 2009
Other: 4% Taxes:10%
Contributions: 49% General Social Contribution: 37%
Collecting and allocating revenues

In the general scheme - which covers all private sector employees - subscriptions, social security contributions and other dedicated levies are collected by a specific branch. The collection branch includes the Central Social Security Organisations Agency (Agence Centrale des Organismes de Scurit Sociale, or ACOSS) and the Associations for Collecting Social Security and Family Benefit Contributions (URSSAF). Administrative management of the three branches of the general insurance scheme, the ACOSS manages and oversees the entire network, which consists of around 100 URSSAFs. In so doing, it
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manages the cash of the general health insurance schemes three branches on a joint basis. The collection branch is also responsible for: Collecting subscriptions: subscriptions are paid to the URSSAF by employers and the self-employed and are then transferred exclusively to the ACOSS account; the portion that corresponds to health insurance contributions is then forwarded to the health insurance branch. Collecting the CSG: the URSSAFs only collect the CSG that is based on employment income and welfare benefits. The CSG payable on income from capital and investments is collected by the tax authorities. The whole amount is forwarded to the ACOSS, which divides it between the various compulsory health insurance schemes.
FOCUS: Reducing the health insurance systems deficit

There are structural reasons for the deficit of the health insurance system, but it is also caused by a circumstantial imbalance. Indeed, the slowdown in growth and the increase in unemployment have resulted in a loss of revenues, which does not enable the increase in healthcare expenditure levels to be offset. In addition to the diversification of funding resources, several regulatory techniques have been implemented to stop these losses: Controlling expenditure through demand: insured persons are called upon to make a greater contribution towards their healthcare coverage. On the one hand, these measures regulate the consumption of treatments while providing additional resources for the health insurance system, on the other. From a practical standpoint, the insured person is made to participate through several systems: the payment of one euro per appointment, the co-payment portion, the flat-rate hospital payment, nonreimbursement for drugs where the medical benefit (SMR) is deemed to be inadequate. Controlling supply: : In addition to public health planning tools (the numerus clausus, the SROS, etc.), the State has introduced several reforms to promote medical management of treatment expenditure. These reforms are primarily reflected in the choice of attending doctor, the co-ordinated treatment path, the prescription of generic drugs and the boosting of private medical practices by introducing Enforceable Medical Benchmarks (Rfrence Mdicale Opposable, or RMO) in order to avoid over-prescribing. The rationalisation of treatment provision also involves improving the consistency and efficiency of the system, like the modernisation of hospital management with the introduction of T2A.
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CHAPTER 11:
Major challenges
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CHAPTER 11: Major challenges

As a whole, international studies (by the European Union, the OECD, and the WHO) have confirmed that France has one of the best-performing healthcare systems in the world. With the development of health insurance, the system is accessible to the entire population, thanks to the combination of compulsory health insurance schemes, top-up health insurance schemes and social cohesion systems like Universal Healthcare Coverage (CMU) or Assistance with Purchasing Top-Up Health Insurance (ACS). However, this system comes at a cost: France devotes around 11% of net gross domestic product (GDP) to healthcare expenditure as a whole, which puts the country in second position world-wide behind the United States, which is well in the lead at 16% of GDP. According to the latest OECD study, which focused on 2008, the average for OECD countries is around 8.9%. Average healthcare expenditure per inhabitant (adjusted on an average currency purchasing parity basis) is US$3,601 in France, compared with US$2,984 for OECD countries as a whole. Like all its counterparts in developed countries, the French healthcare system is currently facing a certain number of challenges. In the short term, the main challenge is undoubtedly that posed by the global economic crisis, which is weighing on the health insurance systems revenues. However, the main challenges are in the medium and long term. Public authorities, like welfare organisations, have already begun to prepare for those challenges. The main challenges are :
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Allocation of funding
Another unique feature of the French system is the high level of healthcare expenditure that is funded by public funds (including health insurance): in 2008, 79% of healthcare expenditure was funded by public funding (compared with an average of 73% for the OECD), compared with 13.7% for the top-up health insurance system, while households remain directly responsible for 7% (18% within the OECD). Measures to turn the health insurance system around that have been taken during the past few years - like the increase in co-payment portions, reduced reimbursement for certain drugs that are not considered essential, and the introduction of system like the 1.00 flat fee - have led to an increase in the share funded by top-up health insurance organisations (which have increased their rates accordingly), as well as in the amount for which households remain responsible. The portion funded by the social security system, strictly speaking, has thus fallen from 77.1% in 1995 to 75.5% in 2008, while the portion funded by top-up health insurance schemes increased from 12.2% to 13.7% during the same period. This trend raises two main issues: The first is the universality of top-up health insurance. Currently, around 7% of the French population has no coverage. Although people with very low incomes can benefit from the top-up CMU or assistance with purchasing top-up health insurance (ACS), low-paid workers - whose income is nonetheless above the ceilings sometimes do not have the means necessary to purchase top-up coverage if they do not benefit from it as part of a company scheme (which is the case for the self-employed and a certain number of small companies). The second issue is the clarity and transparency of top-up health insurance policies, which cover a very wide range of services and costs. A first step has been taken in this area with the introduction of responsible policies, which set out a minimum number of proposed guarantees.
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Long-term conditions
The system for handling Long-Term Conditions (LTCs), which was put in place in 1945, enables people suffering from a long-term and costly medical condition to be fully reimbursed for all the expenses relating to the illness in question. Around 400 illnesses, divided into 30 conditions, entitle patients to avail themselves of this system. The system also includes the 31st illness, a category that corresponds to other illnesses - outside the list of the 30 illnesses defined by decree - which result in a debilitating condition and require treatment for a period longer than six months. France has around 8 million people with long-term conditions (14% of the population) and their number has increased by 5% per year during the past ten years. Long-term conditions account for around 60% of health insurance spending and their amount increases with age (a high proportion of LTCs is linked to aging or gets worse with age). The Law of August 13th 2004 reforming health insurance introduced significant changes, primarily by entrusting responsibilities to the National Health Authority (HAS) (see Chapter 7 for further detail on the HAS). The Agency is mainly responsible for issuing an opinion on the list of LTCs, issuing recommendations on the procedures and treatment provision required to cover LTCs, as well as the medical criteria that justify admitting patients under this system. The work performed by the HAS has already highlighted significant discrepancies on that last point, as well as inconsistencies in the LTC list (type-2 diabetes with no complications is classified as an LTC, although it is not particularly expensive to treat, while other illnesses, which are markedly more expensive, are not classified as LTCs). The LTC reform will therefore represent one of the French healthcare systems main projects for the coming years.
Educating the patient about treatment and prevention

Therapeutic Patient Education, a continuous process that is part of the treatment and is focused on the patient - according to the definition issued by the WHO in 1998- is called upon to play an increasing role in the French healthcare system. Like its foreign counterparts, the system is facing a sharp increase in behavioural or civilisation illnesses. The rapid increase in type-2 diabetes is the best illustration. The health
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insurance system - more especially the National Health Insurance Fund for Salaried Workers (CNAMTS) - has acquired significant expertise in this area. Indeed, therapeutic patient education (TPE) represents one of the priorities of the Targets and Management Agreement (Convention dObjectifs et de Gestion, or COG) signed by the State and the CNAMTS. This is why the latter launched an experimental patient education programme intended for a sample of people suffering from type-2 diabetes in 2008, working together with the Primary Health Insurance Funds (CPAM). This programme, which forms part of a range of services for taking care of chronically ill patients offered to attending doctors, primarily involves 21 Health Assessment Centres (Centres dExamens de Sant, or CES) On a wider basis, prevention will play an increasing role in the French healthcare system over the coming years. The aim is to limit the rapid increase in behavioural illnesses and to lower the avoidable death rate (the percentage of deaths that could have been avoided). This sharp increase in prevention is in line with the extension of the Law of August 9th 2004 on public healthcare policy (see Chapter 6). The health insurance system has already introduced a number of initiatives in this area: setting up dedicated websites, free screening programmes (breast cancer, dental checks for children and young people), prevention appointments for young people, prevention programmes with healthcare professionals (preventing side-effects from drugs among the over-65s, cardiovascular illness prevention programmes, etc.). Moreover, the Regional Health Agencies (ARS) are responsible for preparing and implementing the regional prevention programme, a programme of initiatives that includes rolling-out patient education in the regions.
FOCUS: The MT Dents ( UR Teeth) programme

The MT Dents prevention programme was launched in 2007 as part of the national dental prevention plan and is implemented by the health insurance system. It offers check-up appointments with the dentist of their choice to all children and teenagers at five key ages: 6, 9, 12, 15 and 18. In total, around three million children benefit from the programme every year. Thanks to national and local communication initiatives and to working with the National Education System, the participation rate among children has risen rapidly: 15% in 2007 (the year the programme was launched), 29% in 2008 (and 43 % among six-year old children).
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Medical demographics and treatment provision

In 2008, the number of doctors in regular practice (doctors who are established and have a professional address) fell by 2% in France, for the first time in several decades, decreasing from 203,855 to 199,736, as shown in the 2009 edition of the Atlas de la dmographie mdicale (Medical Demography Atlas), which is published each year by the National Council of the Association of Doctors. Undoubtedly, the total number of doctors registered a slight 0.5% increase, which is explained by the increase in the number of locum doctors or practitioners reporting that they are not working. The combination of this fall in the number of doctors in regular practice and of the growth in the French population has resulted in a slight decrease in the number of doctors per capita, which has fallen from 300.2 to 290.3 doctors in regular practice for 100,000 inhabitants over one year. The number of doctors per capita is beginning to crumble, not only in deprived areas but at the national level too. The issue of treatment provision per capita can be raised on two levels: the overall number of practitioners and their distribution throughout France. The first point can still be controlled. In fact, the public authorities have begun to increase the numerus clausus, which determines the number of students admitted to various university medical faculties (see Chapter 3). Given the length of medical studies and the increasing delay between completing them and setting up a practice (a number of young doctors choose to begin their career as locums), it will take much longer than ten year for the increase in the numerus clausus to begin having an effect on the ground. In order to remedy the lack of enthusiasm for going into private practice - especially general practice - the Government and the health insurance system have also embarked on reviving this specialisation. Improving the distribution of the treatment provision across France is turning out to be markedly harder to achieve. In fact, there are 237.5 practising doctors per 100,000 inhabitants in Picardy, compared with 375 in the Provence Alpes Cte dAzur region. These disparities between regions are accompanied by significant variations within the regions themselves, with increasing gaps between major towns - where students are continuing to set up their practices when they leave teaching hospitals - and less populated areas. These private practice gaps are often mirrored by gaps in the availability of other healthcare professionals, like nurses or massage physiotherapists, often on a much greater scale. As freedom of
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practice location represents one of the basic principles of private medicine, and is recognised by the social security system, the public authorities and the health insurance system have chosen - through the intermediary of local authorities - to put a set of incentives in place to convince practitioners to set up in underprovided areas: helping fund their studies in exchange for a commitment to set up in certain areas, paying them additional compensation, exempting them from certain charges, making premises available to them, developing multi-disciplinary health centres to combat isolation, etc. In 2008 and 2009, the health insurance system signed agreements with private nurses and massage physiotherapists that enable the number of professionals in over-provided catchment areas to be frozen (for nurses, for example, 250 catchment areas account for around 13% of professionals). Conversely, professionals who set up in the same number of under-provided areas will benefit from the reimbursement of their family welfare contributions, from a 3,000 per year investment grant and a higher rate of payment for their procedures (6% for nurses).
Dependency and the fifth risk

Despite Frances dynamic demographics (the highest birth rate in Europe, along with Ireland), the unavoidable aging of the population and the continual increase in life expectancy have made dependency a major challenge for the coming years. Between now and 2030, the number of people aged over 75 will be multiplied by three and the number of people aged over 85 by four. In addition to the need for suitable social and medico-social care, this aging process also raises public health issues. The rapid increase in Alzheimers disease is a case in point. France was one of the very first countries to adopt a structured policy in this area. The 2008-2012 Alzheimers Plan - the second one of its kind - allows for around 40 measures, financed by a package worth over 1 billion. A change of this kind obviously assumes suitable medical and medico-social care. France has begun to prepare for the change by gradually adding a fifth risk to the welfare system, which is entirely devoted to dealing with dependency. The build-up has happened in several stages. Initially, the legislator created specific types of provision. This is how the Personalised Independence Allocation (Allocation Personnalise dAutonomie, or
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APA) was introduced in 2002. That benefit is now paid to 1.1 million beneficiaries. It enables elderly dependent people to benefit from a cash payment, which is calculated according to their loss of independence and their resources, and which can represent up to 1,200 per month. This assistance enables them either to fund services that help them stay in their own home, or to pay the dependency rate in retirement homes. The personalised independence benefit is mainly funded by the departments, with help from the State. In 2006, a similar benefit was introduced for the disabled: the Disability-Offset Benefit (Prestation de Compensation du Handicap, or PCH). As a second step, the Law of June 30th 2004 on social solidarity for the benefit of the elderly and the disabled founded the National Solidarity Fund for Independent Living (Caisse Nationale de Solidarit pour lAutonomie. or CNSA). Now, this organization plays a central role in funding dependency coverage (see box). The third step should be taken in 2011 with the likely submission of a draft law introducing the fifth welfare risk. Dependency will thus be added to illness, workplace accidents, aging and the family 65 years after the social security system was created in its current form. As this document went to press, all the decisions about the fifth risk have not yet been announced. However, we already know that this coverage is likely to combine social solidarity benefits (like the other coverage systems) and a more or less significant contribution from the private insurance sector. In order to encourage the working population to take out coverage against the risk of dependency, the State could introduce tax incentives to encourage people to purchase policies. Management of the fifth risk is likely to be entrusted to the CNSA or to a CNSA body.
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FOCUS: The National Solidarity Fund for the Support of Independent Living (CNSA)
The CNSA was founded by the Law of June 30th 2004 on social solidarity to help the elderly and the disabled to remain independent, and became operational on January 1st 2006. The Fund plays the role of a welfare fund (funding initiatives and benefits) as well as the role of a specialist support agency for all questions regarding dealing with dependency. It is primarily responsible for: - Funding assistance for elderly dependent people and the disabled (in particular, it helps departments fund the APA - Personalised Independence Allocation - and the PCH - Disability Offset Benefit); - Allocating health insurance credits intended to fund medico-social institutions and services for the elderly or the disabled between departments; - Guaranteeing equality of treatment throughout France and for all disabilities; - Fulfilling an expert information and management assignment to monitor the quality of service provided to individuals. The CNSAs budget amounted to 18.57 billion in 2010. It is funded from three main sources. The first two sources are the contributions paid by the health insurance system and the allocation of a portion of the General Social Security Contribution (CSG). The third is more unusual. In fact, it consists of the Social Solidarity Independence Contribution (Contribution de Solidarit Autonomie, or CSA). This contribution is paid by employers (companies and public authorities), in exchange for employees relinquishing one day of their paid holiday.
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BIBLIOGRAPHY
Works Consulted: Amde Thvenet, Les institutions sanitaires et sociales de la France, Que sais-je / PUF, 2002. Ariel Beresniak et Grard Duru, conomie de la sant, ditions Masson, 2007 (6th edition). Pierre Rosanvallon, Ltat en France de 1789 nos jours, collection Points Histoire, Seuil, 1993. Jean de Kervasdou, LHpital, Que sais-je/ PUF, 2004. Patrice Blmont et Pascal Olejniczak, Assurance maladie et systme doffre de soins, llipses, 2007. Dominique Ceccaldi, Danile Moulinot, Dominique Rogeaux, Les institutions sanitaires et sociales, Broch, 2006. Bruno Palier, La rforme des systmes de sant, Que sais-je/ PUF, 2004. Michel Borgetto, Jean-Jacques Dupeyroux, Robert Lafore, Le droit de la scurit sociale, Dalloz, collection Prcis, 2008 (16th dition). Articles : La Sant, Cahiers Franais n324 edited by Olivier Cazenave, La documentation franaise January-February 2005.
Atlas de la Rvolution franaise, volume 7, les ditions de lcole des hautes tudes en sciences sociales, 1993. Hpital, Universalis article by Robert-Frdric Bridgman. Les agences, alternatives administratives ou nouvelles bureaucraties techniques ?, article by Daniel Benamouzig (CNRS/ INSERM/EHESS) and Julien Besanon (Science Po/CNRS), revue Horizons stratgiques, n 3, January 2007 La protection sociale en France, edited by Marc de Montalembert, Les notices de la documentation franaise, 2008.
Online Dossiers: http://www.hopital.fr Files on the Ministry website: http://www.sante-sports.gouv.fr/ liste-des-dossiers-de-a-a-z.html DREES data : http://www.sante-sports.gouv.fr/ direction-de-la-recherche-des-etudes-de-levaluation-et-des-statistiques-drees,5876. html Les dossiers de la documentation Franaise : http://www.ladocumentationfrancaise.fr/
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Table of contents
The French health system The French healthcare system
CHAPTER 1
P. 5 P. 11 P. 19 P. 31 P. 45 P. 55 P. 63 P. 71 P. 85 P. 91 P. 97
History of the healthcare system

CHAPTER 2
Principles, general organisation and management

CHAPTER 3
Out-patient care and healthcare professionals

CHAPTER 4
Treatment institutions
CHAPTER 5
The pharmaceutical sector and the healthcare industry

CHAPTER 6
Public healthcare policy

CHAPTER 7
Public health agencies

CHAPTER 8
Health insurance
CHAPTER 9 CHAPTER 10 CHAPTER 11
Top-up health insurance schemes and access to treatment for all Healthcare expenditure and funding the provision of treatment Major challenges
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GLOSSARY
The French health system Acronym ABM ACOSS ACS AFSSA AFSSAPS French Agence de la Biomdecine Agence Centrale des Organismes de Scurit Sociale Aide lAcquisition dune Complmentaire Sant Agence Franaise de Scurit Sanitaire des Aliments Agence Franaise de Scurit Sanitaire des Produits de Sant AFSSET Agence Franaise de Scurit Sanitaire de lEnvironnement et du Travail AHR Agences Rgionales de lHospitalisation AI Autorisation dImportation ALD Affections de Longue Dure AME Assitance Mdicale de lEtat AMM Autorisation de Mise sur le March ANAP Agence Nationale dAppui la Performance des Etablissements ANSES Agence Nationale de la Scurit Sanitaire de lAlimentation, de lEnvironnement et du Travail APA Allocation Personnalise dAutonomie ARS Agences Rgionales de Sant ASHQ Agent de Services Hospitaliers Qualifi ASIP Agence des Systmes dInformation Partags ASMR Amlioration du Service Mdical Rendu ATU Autorisation Temporaire dUtilisation BPC Bonnes Pratiques Cliniques CAPI Contrat dAmlioration des Pratiques Individuelles CARSAT Caisse dAssurance Retraite et de la Sant au Travail CCAM Classification Commune des Actes Mdicaux CES Centres dExamens de Sant CEPS Comit Economique des Produits de Sant CGS Contribution Sociale Gnralise CGSS Caisse Gnrale de Scurit Sociale CH Centre Hospitalier CHR Centre Hospitalier Rgional CHU Centre hospitalo-universitaire CHR Centre Hospitalier Rgional CHRU Centre Hospitalier Rgional Universitaire CHS Centres hospitaliers spcialiss (en psychiatrie) CHSCT Comit dhygine, de Scurit et des Conditions de Travail CLCC Centre Rgional de Lutte contre le Cancer CME Commission Mdicale dEtablissement CMP Centre Mdico-Psychologique CMU Couverture Maladie Universelle CMU-C Couverture Maladie Universelle- Complmentaire CNAMTS Caisse Nationale dAssurance Maladie des Travailleurs Salaris CNRS Centre National de la Recherche Scientifique CNS Confrence Nationale de Sant CNSA Caisse Nationale de Solidarit pour lAutonomie CNSP Comit National de Sant Publique English Bio-Medicine Agency Central Social Security Organisations Agency Assistance with Purchasing Top-Up Insurance Policy French Food Health Safety Agency French Agency for the Public Safety of Healthcare Products French Agency for Environmental and Labour Health Safety Regional Hospital Agencies (AHS) Importation Authorisation Long-Term Conditions (LTCs) State Medical Assistance Marketing Authorization National Agency for Supporting Medical Institutions Performance French National Agency for Food Health Safety, the Environment and Labour Personalised Independence Allocation Regional Health Agencies (ARS) Qualified Hospital Service Facilitator Shared Information Systems Agency Improved Medical Benefit Authorisation for Temporary Use Best Clinical Practice Contract for Improving Individual Practices Retirement and Health in the Workplace Insurance Funds Common Classification of Medical Procedures Health Assessment Centres Economic Committee for Healthcare Products General Social Security Contribution General Social Security Funds Central Hospital Regional Hospital Centre University teaching hospitals Regional Hospital Centre Regional Teaching Hospital Specialist Psychiatric Centres Hygiene, Safety and Working Conditions Committee Cancer Research Centre Institutional Medical Committee (CME)e Medico-Psychological Centre Universal Healthcare Coverage Universal Top-Up Healthcare Coverage National Health Insurance Fund for Salaried Workers National Centre for Scientific Research National Health Conference National Solidarity Fund for Independent Living National Public Health Committee
108
GLOSSARY
The French health system COG CPAM CPOM CRAM CSA CSBM CSG CSIS CSMF CSP CTE DAEI DDASS DDCS DDCSPP DGCS DGOS DGS DPC DRASS DSS DAEI EFS EHESP EHPAD EPA EPRD EPRUS ESPIC ETP FHP FMC GCS GIE GRSP HAS HPST HSCPS INPES INSERM INVS IRSN LEEM LFSS MCO MARPA Convention dObjectifs et de Gestion Caisse Primaire dAssurance Maladie Contrat Pluriannuel dObjectifs et de Moyens Caisse Rgionale dAssurance Maladie Contribution de Solidarit Autonomie Consommation de Soins et de Biens Mdicaux Contribution Sociale Gnralise Conseil Stratgique pour les Industries de Sant Confdration des syndicats mdicaux franais Code de la Sant Publique Commission Technique dEtablissement Direction des Affaires Economiques et Internationales Directions Dpartementale des Affaires Sanitaires et Sociale Direction Dpartementale de la Cohsion Sociale Directions Dpartementales de la Cohsion Sociale et de la Protection des Populations Direction Gnrale de la Cohsion Sociale Direction Gnrale de lOffre de Soins Direction gnrale de la sant Dveloppement Professionnel Continu Directions Rgionales des Affaires Sanitaires et Sociale Direction de la Scurit Sociale Direction des Affaires Economiques et Internationales tablissement Franais du Sang Ecole des Hautes Etudes en Sant Publique tablissement dHbergement pour Personnes Ages Dpendantes Etablissement Public Administratif Etat des Prvisions de Recettes et de Dpenses tablissement de Prparation et de Rponses aux Urgences Sanitaires Etablissement de Sant Priv dIntrt Collectif Education Thrapeutique du Patient Fdration Hospitalire de France Formation Mdicale Continue Groupement de Coopration Sanitaire Groupement dIntrt Economique Groupement Rgional de Sant Publique Haute Autorit de Sant Hpital, Patients, Sant et Territoires Haut Conseil de la Sant Publique Institut National de Prvention et dEducation pour la Sant Institut National de la Sant et de la Recherche Mdicale Institut de Veille Sanitaire Institut de Radioprotection et de Sret Nuclaire Les Entreprises du Mdicament Loi de Financement de la Scurit Sociale Soins Griatriques de Court Sjour Maison dAccueil Rurales pour Personnes Ages Targets and Management Agreement Primary Health Insurance Fund Multi-Year Aims and Means Contract Regional Health Insurance Fund Social Solidarity Independence Contribution Consumption of Medical Treatments and Goods General Social Security Contribution Strategic Council for the Healthcare Industries French Federation of Medical Unions French Public Health Code Institutional Technical Committee Department of Economic and International Affairs Departmental Public Health and Welfare Department Departmental Social Cohesion Departments Departmental Departments for Social Cohesion and Protection of the Population General Department for Social Cohesion General Treatment Provision Department General Health Department Continuing Professional Education Regional Public Health and Welfare Department Social Security Department Department of Economic and International Affairs French Blood Transfusion Agency School of Higher Studies in Public Health Nursing Homes for Elderly Dependent People Public Administrative Institution Statement of Forecast Income and Expenditure Organisation in Charge of Preparing for and Responding to Public Health Emergencies Public Interest Private Healthcare Institution Therapeutic Patient Education (TPE) Hospital Federation Ongoing Medical Training Public Health Co-operation Group Economic Interest Group (EIG) Regional Public Healthcare Cluster National Health Authority Hospital, Patients, Healthcare and Regions High Council for Public Health National Healthcare Prevention and Education Institute National Health and Medical Research Institute Public Health Monitoring Agency French Institute for Radioprotection and Nuclear Safety French Pharmaceutical Companies Association Social Security Funding Bill Short-Term Geriatric Care Rural Retirement Homes for the Elderly
109
GLOSSARY
The French health system MEP MSA MSP NGAP OCDE Mdecin Libral Mode dExercice Particulier Mutuelle Sociale Agricole Maison de Sant Pluridisciplinaires Nomenclature Gnrale des Actes Professionnels Organisation de coopration et de dveloppement conomique ONDAM Objectif National de Dpenses dAssurance Maladie ONDPS Observatoire National de la Dmographie des Professions de Sant PCH Prestation de Compensation du Handicap PIH Prescription Initiale Hospitalire PNNS Programme national nutrition sant PNSE Plan National Sant Environnement PU-PH Professeur des universits-praticien hospitalier RGPP Rvision Gnrale des Politiques Publiques RH Rserve Hospitalire RMO Rfrence Mdicales Opposable RSI Rgime Social des Indpendants SMR Service Mdical Rendu SPH Service Public Hospitalier SROS Schma Rgional dOrganisation Sanitaire SSIAD Structures de Soins Domicile SSR Soins de Suite et de Radaptation T2A Tarification lActivit TNB Table Nationale de Codage de Biologie UFR Unit de Formation et de Recherche UGECAM Union des Gestionnaires des Etablissements des Caisses dAssurance Maladie UNCAM Union Nationale des Caisses dAssurance Maladies UNOCAM Union Nationale des Organismes dAssurance Maladie Complmentaire UNPS Union Nationale des Professionnels de Sant URMEL Union des Mdecins Exerant Titre Libral URSSAF Union pour le Recouvrement des Cotisations de Scurit Sociale et dAllocations Familiales USLD Units de Soins de Longue Dure Private Special Interest Practitioner Agricultural Workers and Farmers Mutual Benefit Fund Multi-Disciplinary Health Centres General Classification of Professional Procedures OECD National Health Insurance Spending Target National Observatory for the Demographics of Healthcare Professionals Disability-Offset Benefit Initial Hospital Prescription National Nutrition and Health Programme National Health and Environment Plan University Professors-cum-Hospital Consultants General Public Policy Review Hospital Stock Enforceable Medical Benchmark Social Security Scheme for the Self-Employed Medical Benefit Public Hospital Service Regional Public Health Organisation Programme In-Home Care Nursing Care Services Follow-Up and Rehabilitation Care Rate-Setting per Activity National Table of Biology Codes Training and Research Unit Health Insurance Fund Managers Union National Union of Health Insurance Funds National Union of Top-Up Health Insurance Organisations National Union of Healthcare Professionals Union of Private Doctors Association for Gathering Social Security and Family Benefit Contributions Long-Term Treatment Units
Document edited by GIP SPSI Director of publication: Agns Plassart, representative of the GIP SPSI Editor: Xavier Chambard, Head of Communications Design and Text: PCA Translation : alter ego traduction Graphical design and production: Projectil September 2010
Reproduction of the texts is permitted as long as GIP SPSI is mentioned as the source.
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English - French Health System

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Organisation

History of the healthcare system

CHAPTER 1: History of the healthcare system

I - The emergence of healthcare organisations

The gradual secularisation of hospitals

CHAPTER 1: History of the healthcare system

The State as protector

The Hygienic State

Socialisation of the demand for healthcare

CHAPTER 1: History of the healthcare system

II - A socially responsible healthcare system

CHAPTER 1: History of the healthcare system

A universal healthcare system

Public Hospital and Sanitation Planning Department

1 See health insurance chapter

CHAPTER 1: History of the healthcare system

Regional management of the healthcare system

Principles, general organisation and management

CHAPTER 2: Principles, general organisation and management

The uniqueness of the French hospital system

I - The principles of a pluralistic system

CHAPTER 2: Principles, general organisation and management

Reimbursement of healthcare expenses

CHAPTER 2: Principles, general organisation and management

The French Carte Vitale health insurance card

Socialisation of health insurance

CHAPTER 2: Principles, general organisation and management

II - Organisation and regulation of the French healthcare system

2 See chapter on health insurance, p 71 3 See chapter VII on Healthcare Agencies, p 63

CHAPTER 2: Principles, general organisation and management

The role of Parliament

The role of the Government

CHAPTER 2: Principles, general organisation and management

A trend towards regionalisation...

CHAPTER 2: Principles, general organisation and management

Out-patient care and healthcare professionals

CHAPTER 3: Out-patient care and healthcare professionals

CHAPTER 3: Out-patient care and healthcare professionals

CHAPTER 3: Out-patient care and healthcare professionals

1 - 2009 French Medical Demography Atlas, (French Medical Council)

CHAPTER 3: Out-patient care and healthcare professionals

CHAPTER 3: Out-patient care and healthcare professionals

CHAPTER 3: Out-patient care and healthcare professionals

B - A highly regulated profession

CHAPTER 3: Out-patient care and healthcare professionals

CHAPTER 3: Out-patient care and healthcare professionals

CHAPTER 3: Out-patient care and healthcare professionals

II - Paramedical and similar professions

A- The regulated paramedical professions

CHAPTER 3: Out-patient care and healthcare professionals

B- The other professions

CHAPTER 3: Out-patient care and healthcare professionals

CHAPTER 4: Treatment institutions

I - The hospital system

B- The hospitals duties

CHAPTER 4: Treatment institutions

CHAPTER 4: Treatment institutions

II - the French hospital sector

CHAPTER 4: Treatment institutions

Health care establishments (1)

Status Modes of financing

A - Public health institutions