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