The French Healthcare System

1. The French Healthcare System Lecture 7 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

2. The Best in the World • A very controversial study released by the World Health Organization in 2000 declared France had the BEST healthcare system in the world! • Still the French citizens were dissatisfied!

3. Where are we now? French Republic (France) Capital: Paris Population: 60,876,000 Government: Republic Divisions: 22 Regions, 96 Departments

4. Updated Facts about France • Life Expectancy: 76.1 m/ 83.5 f (2006) • Infant Mortality: 4.21 per 1000 (2006) • Population >65: 16.4% (2006) • Health care expenditures as percent of GDP: 9.7 (2002) • Per capita health expenditure: $2762 US • Leading causes of mortality: cancer, heart disease

5. Organization • Ministry of Health—runs two large organizations that cover the funding and provision of health services: • General Health Management • Hospital and Healthcare Management • 22 Regional level service organizations • 96 departmental level services organizations

6. Public Health Agencies in France • National Institute of Health (1998) • French Agency of Health Safety of Health Products: (1998) (like our FDA) reviews drugs, cosmetics, foods • Agency of Environmental Health Safety (2000) • French Institute of Blood (1992): safe blood • French Institute of Transplants: (1994)—arms and faces! • Ministry for Health, Family and the Disabled

7. Planning The government presents a law to parliament every year in order to finance social security which includes the national expenditure on health insurance. Delineates specific goals for the healthcare system. • Ministry of Health—delegates to the Regions who develop: • General Regional Health Organization Plans

8. How does French Health Insurance Work? • National Health Insurance (NHI) guarantees universal access • Administered in schemes according to occupation • 80%: CNAMTS, salaried workers and their families • The rest: 17 separate funds—occupationally specific, doctors, agricultural workers, students

9. Financing the French Healthcare System • 60% from workers salaries go into the health insurance branch of social security • The rest is from indirect taxes on alcohol and tobacco and by direct contribution paid by all revenue in proportion to income including retirement pensions and capital revenues. • More than 80% of French people carry a supplemental form of private insurance often linked to employment

10. Paying for care • Public payment covers 76% of French health expenditure • 21% of expenditures are on pharmaceuticals • Patients pay the physicians directly and apply for reimbursement • For 96% of the population, health care is entirely free of reimbursed up to 100%. • This is a new change as of 2005 • Previously 80% with 100% for specific diseases like AIDS, diabetes • Or certain “conditions”: pregnancy, handicapped children, invalids, injured workers

11. Freedom of Choice • Since 2005 the French have to select a Gate Keeper physician, however… • Users can select any doctor—even a specialist • Users can select any hospital—public or private • The belief is that choice has led to successfully managed competition and quality care

12. Health Services Workforce • >1.2 million employees in the health service sector • Many public hospital jobs are considered undesirable and filled by foreign doctors • More than 185,000 physicians

13. Health Services Workforce • Majority of physicians in private practice • Many participate in a government fixed fee-for-service scheme (Sector 1) • Others charge what they wish, accept the government payment, patient picks up the rest • French GP’s make about $55K per year • Physicians are unevenly distributed between rural and urban areas

14. More about Physicians • About 50% of physicians are women • Physician visits can take 15 to 30 minutes • Physicians see about 10 patients per day • Publicly funded medical education

15. Hospitalists • 1:1 ratio of generalist to specialist physicians • National-wide ranking system of hospital practitioners • Physicians, biologists, and dentists are all salaried as hospital practitioners • Advancement is based on seniority

16. Hospitals • Global budgeting based on prior expenditures • Public, Private, Not-for-Profit • The mix of public and private avoids long wait lists as in other socialized medicine systems. • Public: About 1032, with 65% of all hospital beds • 91% financed by endowment funding from health insurance funds • Centers of research and medical training • Various levels (large Parisian to small rural)

17. More on Hospitals • Public Hospital example: • Public Assistance Hospital of Paris • Created after the French Revolution • Today it employs over 80,000 people • Complex organization responsible for a high standard of medical care, technology and research

18. Private, Not-for Profit • Private, Not-for-Profit: • 15% of French hospitals • Specialize in medium to long-term care • Many of these hospitals throughout Europe trace their roots back to first era of Christianity (old religious affiliations—health, alms, healing)

19. Private, For-Profit Hospitals • Private, For Profit • 20% of total beds • Started by surgeons and obstetricians but evolved into hospitals • The Private sector conducts: • 50% of surgeries • 60% of cancer care

20. The French Approach to Hospitalization • CHOICE is a number one priority to the French healthcare consumer • The excellence of procedural service is the paramount decision item • However, things like access to bottled water, private rooms and high quality food are taken for granted across hospital settings (unlike in England or US)

21. Long Term Care • France has a tradition of long term care in the home—dating to the 1962 Laroque Report • France maintains strict boundaries between health and social services (like US) • Home health and nursing homes are means-tested • Aid is in the form of APA (Allocation for Loss of Autonomy)—6.4 of the over 60 pop. • APA recipients must use the money to purchase care—even from family members or other unskilled labor (a means to promote employment)

22. Nursing Homes • Many are denominationally based • > 50% of patients have dementia and are over age 80 • Room and board are separate from nursing/health care and are paid from pension funds or covered by welfare funds • Residents are legally entitled to be involved in the governance of their home • Nursing homes have a strong public reputation (unlike in US)

23. Compared to US • The French have the #1 healthcare system in the world. The US is #37. • The French system is universal, US excludes 44 million uninsured individuals • Like US, the French are leaders in technology and research (transplant center in every region, HIV/AIDS research) • French costs are on the rise too—we will have to wait and compare!

24. Parting Shots • Let’s talk about resources for YOUR country project • WHO www.who.int • CIA www.cia.gov • Other places: • AARP (Long Term Care) • OECD, PAHO, CIVITAS (UK)