ENTITIES AND PUBLIC POLICIES
29 november 2017
THE FUTURE OF HEALTH INSURANCE
Ensure the efficiency of spending,
empower the actors
The health insurance system created in 1945 has enabled France to show good results
in terms of life expectancy. However, the prevalence of practices at risk, a high infant
mortality rate and increasing inequalities in access to care, qualify these results, which,
moreover, are obtained at the expense of recurrent deficits. France is characterized by
high health spending as a proportion of GDP and the large share of supplementary health
insurance in its financing. Faced with the structural increase in spending, while the
current regulatory tools have reached their limits, quality and equal access to care can
only be maintained or strengthened by reforming the organization and the management
of the health system.
Satisfactory results overall but persistent weaknesses
France is characterized by one of the highest levels of life expectancy in the world, but also by
high mortality linked to the prevalence of avoidable risk behaviours (alcohol, tobacco).
Difficulties are developing or worsening in areas of public health, access to care, equality and
quality of patient coverage and support for health professionals.
Persistent deficits and a significant social security debt undermine the strength and legitimacy
of the health system by putting the burden on subsequent generations, while the ageing of the
population, the development of chronic diseases and the rising cost of care techniques imply
increasing funding difficulties.
Spending containment policies are too often flawed
The Cour has identified efficiency issues in the organization of the healthcare system amounting
to several billion euros. However, existing tools do not enable the obstacles that prevent
improvement in services and reduce their cost to be overcome. In addition to the necessary
streamlining of its organization, health insurance could be given more ambitious objectives, such
as redefining the respective areas of mandatory and complementary coverage, or setting up a
"healthcare shield" that will equitably limit the excess to be paid by the patient. Price excesses,
which hinder equal access to care, should be better controlled, and the conventional negotiation
framework reviewed in depth. As is the case in Germany, healthcare professions could be more
accountable in terms of installation, contractual agreements and remuneration.
The division of competences between medical practitioners and auxiliaries, as well as the
modalities for their cooperation, should also be reviewed. Better coordination between
community medicine and hospitals, which is necessary in particular to improve the response to
medical emergencies, involves breaking away from the current logic, centered on the hospital,
to build real care pathways.
Regulatory methods held in check
The Cour has identified several flaws in the health system, which should be remedied: a costly
predominance of the hospital, the lack of regulation of heavy healthcare equipment,
compartmentalization among professions, territorial distribution of supply of care that is
unbalanced and disconnected from needs, poor planning, inoperative rules on the installation of
professionals and shortcomings in health insurance coverage decisions.
In addition, the current mode of remuneration for facilities and professionals, discussed in a
partnership framework that is often impeded, encourages the multiplication of acts, becomes far
removed from real costs and does not take enough account of public health objectives.
Prioritize public health and quality of care objectives
Prevention, which is insufficient in France, must be reorganized and placed at the heart of public
action by involving and empowering patients and health professionals. The appropriateness,
quality and safety of care could be the central axis of a reform that should also focus on fighting
fraud more effectively and strengthening controls. In this respect, the digitisation of healthcare
provides the opportunity, through active exploitation of data, to improve treatments and
prevention, to better coordinate care and to develop telemedicine.
The steering of the healthcare system needs to be clarified and the means of action available to
regional health agencies strengthened, by envisaging, in particular, spending envelopes at the
regional level, which would allow for restructuring of healthcare provision to be more ambitious
and better adapted to needs. The creation of a National Health Agency, bringing together the
competencies of central administration and health insurance, would also be a step forward.
The Cour has formulated 17 recommendations centered on seven key issues:
revamp the framework for health insurance financial management;
reorganise health insurance;
make access to care more equitable;
better organize the healthcare system to adapt it to the needs of patients;
ensure quality and safety of care in all areas;
encourage the optimal use of health insurance resources;
reunify and strengthen the steering of the healthcare system.
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