PUBLIC FINANCES AND ACCOUNTS
SOCIAL SECURITY
Report on the implementation of the So-
cial Security Finance Acts
Executive summary
October 2021
2
g
NOTICE
The purpose of this document is to facilitate the reading of the
Court of Accounts' report, which alone commits the Court. The
responses of the administrations and agencies concerned are
included in the Court's report.
The order of the summarised chapters corresponds to that of the
report.
Summary of the 2021 social security report
3
Summary of the 2021 social security report
Contents
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
1
Curb social security expenditure and indebtedness
7
1 -
The financial trajectory of social security from 2020:
the challenge of the pandemic’s consequences
8
2 -
Social security finance acts: a framework requiring reform
12
3 -
Health insurance expenditure: a regulation requiring reform
14
2
Exiting crisis management methods
19
1 -
Social security funds during the pandemic: initial findings
19
3 -
Telehealth: tools to use to coordinate care
24
4 -
Medical biology expenditure: efficiency efforts still insufficient
26
3
Relaunch and accelerate management reform and
improvement projects
29
1 -
Follow-up and rehabilitation care, psychiatric care, reception of
dependent elderly people and people with disabilities: ten years of
unsuccessful reforms in the financing of agencies and services
29
2 -
Medical e-prescription: a factor in the efficiency of the health
system, ambitious projects to be completed
31
4
Contents
3 -
Recognition and compensation for work accidents and
occupational illnesses: a complex system that needs to be
modified
34
4 -
The basic old-age pension and the back-to-school allowance:
a strong contribution to poverty reduction, mixed management
performances
37
Summary of the 2021 social security report
5
Presentation
The consequences of the pandemic will have a lasting effect on the situation of
government finances and in particular social finances . Close to break-even point
in 2019, the basic social security schemes and the old-age solidarity fund (FSV)
posted a deficit of an unprecedented magnitude (€39 .7 billion) in 2020 . According
to the forecasts of the Social Security Finance Act for 2022, they will still see a
very high deficit in 2021 (€34 .8 billion in forecast deficit) .
Beyond 2021, according to the stability programme sent to the European
Commission in the spring, the Government's objective is to reduce, without tax
increases, the public deficits resulting from the pandemic and to stabilise the
public debt ratio, then to initiate its decrease by 2027 . The Court notes, however,
that the conditions for the recovery of social finances are yet to be defined . It
feels it is necessary for this to be organised based on reforms to be initiated in the
fields of pensions and health in particular .
This report, successively:
- conducts an in-depth analysis of the situation in the social security accounts and
formulates recommendations concerning, firstly, possible ways to improve the
content and methods of drafting social security finance acts and, secondly, the
conditions enabling more effective control, over the long term, of changes in
health insurance expenditure (part I);
- conducts the first appraisals of the management of social security during the
pandemic by emphasising that, overall, although the responses to the crisis were
useful, this was most often the case in exceptional conditions and according to
exception rules that are now best fully avoided (part II);
- illustrates, through four examples, the need to relaunch management reform or
modernisation projects, which had to be suspended or slowed down during the
pandemic (part III) .
Summary of the 2021 social security report
7
1
Curb social security expenditure
and indebtedness
Relative to GDP, France's public deficit
was, in 2020, the sixth highest among
the 19 eurozone countries, nearly two
points of GDP higher than the average
measured for these countries and five
points of GDP higher than Germany's .
The pandemic, which has affected
all countries to varying degrees of
intensity, is not the only explanation
for this situation . Before the onset of
the crisis, France had less leeway than
most of its European partners because
of the levels of national deficit and
debt . In 2019, the rate of compulsory
levies in France reached 45 .5% of
GDP, the highest rate in the European
Union, more than five points of GDP
above the eurozone average (40 .4%)
and Germany (40 .3%) . French public
expenditure was also the highest in the
European Union, reaching 55 .5 points
of GDP, or 8 .8 points of GDP above the
average in EU countries (46 .6 points) .
O ve r 2 0 ye a r s , b et we e n 2 0 0 0
and 2019, the increase in public
expenditure's share of GDP (+4 .5
points) can be attributed to changes
in social expenditure: +2 .8 points for
pension expenditure and +1 .7 points
for public health expenditure . In
the report submitted to the Prime
Minister
1
on the public finance strategy
in relation to the end of the pandemic,
the Court stressed the need to
consolidate government finances, in
particular by moderating the increase
in social expenditure . The first two
areas in which it recommends action
are old-age insurance, an aspect that
is not examined further in this report,
and health insurance, an issue that is
covered in several chapters .
Summary of the 2021 social security report
1
Court of Accounts, "A government finance strategy for exiting the crisis", June 2021 .
8
Curb social security expenditure and indebtedness
Following the fall in revenue that
took place in 2020 and that has
been partially offset since, the sharp
increase since 2020 in health insurance
expenditure linked directly and
indirectly to the pandemic has caused
a profound and significant imbalance
in the social security accounts, an
analysis of which is the subject of the
first chapter of the report (chapter I) .
To help better control the rise in
social expenditure, improvements
in the organisation and scope of
social security finance acts could
be useful (chapter II) . A more
rigorous interconnection between
the objectives of controlling health
insurance expenditure and actions
a i m e d at b e t te r m e e t i n g t h e
population's health needs through
more relevant and quality care also
appears essential (Chapter III) .
1 - The financial trajectory of
social security from 2020: the
challenge of the pandemic's
consequences
The Covid-19 crisis has caused a
long-term disruption in the financial
trajectory of social security .
An unprecedented deterioration in the
social security accounts in 2020
In 2020, the aggregate deficit of
the mandatory basic social security
schemes and the Old-Age Solidarity
Fund (FSV) reached €39 .7 billion, or
1 .7% of GDP, including €38 .7 billion for
the general scheme and the FSV . This
deficit exceeds that recorded in 2010
(1 .5% of GDP), following the economic
recession caused by the financial crisis
of 2008-2009 .
Summary of the 2021 social security report
Change in the aggregate deficit of basic mandatory social security and FSV schemes
(2008-2020, in €bn)
-40
-30
-20
-10
0
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
-8.9
-24.9
-29.6
-22.6
-19.2
-16
-12.8
-10.2
-7
-4.8
-1.4
-1.7
-39.7
Source: accounts of the social security and FSV schemes
9
Curb social security expenditure and indebtedness
Summary of the 2021 social security report
Compared to the forecast of the 2020
Social Security Finance Act (LFSS),
the deficit of the general scheme and
the FSV increased by €33 .2 billion (by
€36 .8 billion compared to 2019) . All of
the social security branches recorded
deficits, even the family and AT-MP
branches, which were structurally
in surplus . The healthcare branch
recorded the largest deficit (€30 .4
billion) .
The increase in the deficit in 2020 is
due to a combination of unfavourable
developments affecting both revenue
and expenditure .
Revenues from the general scheme
and the FSV fell by €11 .8 billion
(-2 .9%) compared to 2019 and €18 .8
billion (-4 .6%) compared to the
forecast of the 2020 LFSS, due to:
- the decline in economic activity
(-7 .9%) and the fall in employment
(-1 .2%);
- the widespread use of short-time
working subject to lower social
security contributions (absence of
employer contributions and the
generalised social contribution rate of
6 .2%, versus 9 .2% for earned income),
which involved an average of three
million workers in 2020;
- the government decision to halve the
base of professional income used to
calculate social security contributions
for self-employed workers in 2020, in
order to ease their cash flow situation;
- the increase in provisions for the
risk of the non-recovery of URSSAF
(organisations for the payment of
social security and family benefit
contributions) debt commitments
from businesses and self-employed
workers, from €1 .6 billion in 2019 to
€7 .5 billion in 2020 .
Conversely, expenditure increased
by €24 .9 billion (+6 .2%) compared to
2019, including €14 .6 billion over the
forecast recorded in the 2020 LFSS,
mainly concerning the healthcare
branch . The national healthcare
expenditure target (ONDAM) was
exceeded by nearly €14 billion, thereby
increasing 9 .5% compared to 2019,
versus an expected increase of 2 .45% .
This is because the pandemic has
resulted in additional expenditure:
purchases of masks and other personal
protective equipment, screening tests,
compensation for the additional
operating costs of healthcare and
medical-social agencies (including
"Covid" premiums) and specific daily
allowances . In addition, common law
allowance expenditure has soared .
Furthermore, the pay rise measures in
healthcare and medical-social agencies
provided for by the "Ségur de la santé"
agreements caused €1 .4 billion in
additional expenditure in 2020 .
A limited reduction in the deficit in
2021
The draft Social Security Finance Act
for 2022 includes a slight reduction
in the deficit of the general scheme
and the FSV: in 2021, this would total
€34 .6 billion, including €30 billion for
the healthcare branch .
The strong recovery in economic
activity, employment and consumption
is driving up revenue (+7 .9%) .
10
Curb social security expenditure and indebtedness
Summary of the 2021 social security report
However, expenditure looks to be
increasing almost as quickly . In 2021,
the "Ségur de la santé" measures are
ramping up (+€7 .9 billion anticipated) .
In addition, the gross additional costs
directly linked to the pandemic (€14 .8
billion) are very much higher than the
initial forecast (€4 .3 billion) . This is due
in particular to vaccination-related
expenditure (nearly €5 billion), as well
as the cost of screening tests (over €6
billion) .
Define a rebalancing path focused on
controlled expenditure
At the end of 2021, the social debt
borne by the social security debt
repayment fund (CADES) and the
central agency for social security funds
(ACOSS) could reach €166 billion (or
6 .8% of GDP) . In two years, it will have
increased by €51 billion compared to
the end of 2019 (€115 billion) .
Beyond 2021, the draft Social Security
Finance Act for 2022 provides for a
deficit in the general scheme and the
FSV of around €22 billion in 2022 and
€15 billion in 2023 . From 2024, the
deficit would no longer be reduced and
would stagnate at around €13 billion .
Based on these forecasts, the cap of
€92 billion for authorising the reversal
of deficits by the CADES for the
financial years 2020 to 2023, set by the
law of 7 August 2020, will not cover
the 2023 deficit .
There is a high risk that the deficit will
permanently exceed €10 billion from
2024 . The pandemic and its direct and
indirect consequences have disrupted
the financial situation in social security .
Firstly, definitive social revenue
losses are inevitable due to the fall
in economic activity in 2020 and
despite the strong recovery observed
since . Secondly, health insurance
expenditure will be higher by around
€30 billion compared to 2019, beyond
the expenditure directly linked to the
pandemic: the "Ségur de la santé" will
generate €12 .5 billion of additional
spending in 2022, i .e . the equivalent
of 0 .5% of GDP, including nearly
€10 billion in long-term pay rises .
Other recent decisions concerning
hospitals, health products and
community medicine are contributing
to an increase in health insurance
expenditure .
Rebalancing the social security
accounts is essential so that today's
social benefits are no longer partly
financed by borrowing, and therefore
by future generations .
To this end, it is appropriate to
allocate to the reduction of deficits
– rather than to new expenditure –
any additional revenue compared
to forecasts . It is also important to
initiate resolute actions to improve the
efficiency of expenditure, particularly
in the fields of health insurance and
pensions, in order to significantly
reduce their increase compared to
current forecasts .
Appendix: opinion on the consistency
of the balance schedules and of the
schedule Opinion on the balance
schedules and the social security
asset schedule concerning the 2020
financial year.
11
Curb social security expenditure and indebtedness
Summary of the 2021 social security report
Recommendations
1.
Review the procedures for
e s t a b l i s h i n g , v a l i d at i n g a n d
transmitting to the Court the
balance schedules, the details of
the restatements made from the
accounts of entities included in
their scope and the elements of
the draft appendix 4 that pertain
thereto, so that the Court is, in all
cases, in a position to communicate
to Parliament its opinions on their
consistency within the timeframe
resulting from the organic provisions,
in force as anticipated, of the social
security code (ministry for security
social) .
2.
(reiterated recommendation)
End the contractions of income and
expenses in the balance schedules,
which do not comply with the
normative framework set by the
organic law on social security finance
acts, for the establishment of the
accounts of the mandatory basic
social security schemes (ministry for
social security) .
2
Given their particular scope, the uncertainties affecting the 2020 accounts of the recovery
activity did not allow the Court to express an opinion on them . With regard to the branches
of services of the general scheme (excluding recovery activity), the Court made six additional
reservations regarding their 2020 accounts (22 reservations, versus 16 for 2019) . Firstly, these
are linked to the findings concerning the accounts of the recovery activity . In general, the pre-
existing reserves have been strengthened, see
Court of Auditors, Certification of the French
general social security system financial statements and the CPSTI
, May 2021 .
Pursuant to the organic law on social
security finance acts, the Court verified
the consistency of the balance schedules
and the asset schedule of all the
schemes and agencies constituting social
security, concerning the 2020 financial
year, the last closed accounting year,
before they are submitted for adoption
by Parliament in the Social Security
Finance Act for 2022 .
T h e C o u r t e n s u r e d t h a t t h e
information appearing in this
combined (consolidated) social
security income statement and
balance sheet complied with the
accounting data of the social agencies,
that the reciprocal transactions
b et we e n t h e m we re co r re c t ly
eliminated and that information
delivery to Parliament was high-
quality .
The Court considers that, subject to
certain observations concerning in
particular the consequences of the
opinions it issued in connection
with the certification of the French
general social security system financial
statements
2
, the schedules provide a
coherent depiction, firstly, of income,
expenditure and the balance (balance
schedules) and, secondly, of the assets
and liabilities (asset schedule) of the
social security entities included in their
respective scopes .
12
Curb social security expenditure and indebtedness
Summary of the 2021 social security report
2 - Social security finance acts: a
framework requiring reform
The Social Security Finance Acts (LFSS)
were introduced in 1996 . While the
Parliament adopted at first reading a
bill reforming the organic framework
of the LFSS, the Court wished to make
known its analyses on the changes that
could be made to the LFSS to improve
the management of social expenditure .
The LFSS: a keystone of the financial
governance of social security
Every year, a draft LFSS prepared
by the Government submits in the
autumn for approval by Parliament
the expenditure, income and balances
recorded for the past year, the
expenditure objectives, the income
forecasts and balance forecasts for the
coming year and updated objectives
and forecasts for the current year .
N eve r t h e le s s , t h e L F S S co u ld
make a stronger contribution to
the transparency of the choices
concerning policies and social finances
and to the restoration of the financial
position of social security .
Information for Parliament needs to be
expanded
The annual LFSS in the autumn
performs the function of recording the
results of the past year, which is now
neglected . As the Court recommended,
the current revision of the organic law
on the LFSS includes the creation of
a law approving the accounts of the
past year in the spring, as is the case for
central government, in order to more
effectively assess, year by year, changes
in the balance and performance of the
social protection system .
However, the expected progress in the
creation of laws approving the social
security accounts depends in part on
the provision to Parliament of more
complete information .
In the laws approving the accounts,
as in the annual LFSS, information on
income and expenses would benefit
from being provided in a more detailed
manner, by type or by scheme .
In addition, the appendices to the draft
social security finance acts should
provide a better explanation of:
- the assumptions used for the
expenditure, revenue and balance
trajectory for the next four years
s u b m i t te d fo r p a r l i a m e nt a r y
approval;
- the items determining the change
in the expenditure of the various
branches, by separating in particular
the price effects from the volume
effects;
- the loss of revenue, before any
offsetting, linked to exceptional rules
on deduction ("social niches");
- the performance of social security
funds in the proper payment of
benefits .
The framework for the financial
management of social security needs
strengthening
Other changes to the LFSS appear
desirable:
- the establishment of an obligation
for the Government to table, during
the year, a draft amending law in the
event of substantial questioning of
the forecasts approved the previous
autumn, as regularly takes place with
the central government budget;
13
Curb social security expenditure and indebtedness
Summary of the 2021 social security report
- the extension of forecasts to all social
protection expenditure, particularly
that of supplementary pension
insurance and unemployment
insurance, in order to make the scope
of the LFSS coincide with that of
the social security administrations
(ASSO) used as part of the overall
m a n a g e m e n t of g o v e r n m e n t
finances;
- the strengthening of consistency
between the LFSS and the multiyear
public expenditure programming
adopted by Parliament (public finance
programming laws) or submitted to
the European Commission (annual
stability programme);
- the inclusion in the Budget Act of
forecasts of structural efforts and
balances;
- making any new debt takeover by the
CADES concerning forecast deficits
conditional upon the adoption of a
path of recovery in the social security
accounts .
Recommendations
3.
To guarantee the coherence of
the overall management of public
expenditure, extend the scope of
the social security finance acts to
complementary and unemployment
insurance schemes and link the
annual and multiyear expenditure
objectives of the social security
f i n a n ce ac t s to t h o s e of t h e
government finances framework
documents (programming laws,
economic, financial and social report
and stability programme) (ministry
for social security, ministry for the
economy and budget) .
4.
To shed light on the paths for the
financial recovery of social security,
integrate structural effort and
balance forecasts into the social
security finance acts and estimates
of the structural effort and balance
concerning the last financial year
for the future laws approving the
accounts (ministry for social security,
ministry for the economy and
budget) .
5.
Contribute to the management
of the expenditure objectives set by
the annual social security finance act
and the public finance programming
bill, by integrating into the budget
bill and the future bill approving
the accounts submitted for the
Parliament's approval a summary
table of the differences affecting
the balance and a report proposing
measures intended to offset them in
whole or in part (ministry for social
security, ministry for the economy
and the budget) .
14
Summary of the 2021 social security report
Curb social security expenditure and indebtedness
6.
Provide for an obligation to submit
a Supplementary Budget Act when
the conditions for financial balance
adopted in the Initial Budget Act
are called into question (ministry
for social security, ministry for the
economy and budget) .
7.
Incorporate the reversals of
d ef i c i t s by t h e C A D E S ( d e bt
reversals), when these operations
concern provisional deficits, into a
multiyear trajectory for the recovery
of the social security accounts, by
extending the exclusive domain of
the social security finance acts to
these recoveries and by submitting
in this context to Parliament a report
documenting recovery measures
(ministry for social security, ministry
for the economy and budget) .
8.
Improve the conditions for the
exercise by Parliament of its
constitutional mission of controlling
social finances, notably by detailing
at an appropriate level expenditure
and revenue by type, by stating all
of the assumptions underlying the
multiyear financial trajectory and
by stating all of the data in millions
of euros, in the budget bills, as well
as the approval of the accounts
(ministry for social security, ministry
for the economy and budget) .
3 - Health insurance
expenditure: a regulation
requiring reform
In 2020, the Court highlighted in the
report on the implementation of
the social security finance acts the
contributions of the establishment of
the national healthcare expenditure
target (ONDAM) and the associated
r e g u l a t o r y m e c h a n i s m s . I t
nevertheless stressed the importance
of defining a multiyear programme
capable of improving the quality of
care while controlling its cost for the
community .
Once again this year, given the
challenge and the difficulty of
implementing these guidelines,
the Court wished to explore the
issue of regulating health insurance
expenditure in greater depth .
The ONDAM: an essential framework
to be supplemented
For around ten years and until just
before the pandemic, the ONDAM and
the associated regulatory tools made
it possible to curb the rise in health
insurance expenditure . Nevertheless,
this remains at a very high level as a
percentage of national expenditure .
15
Curb social security expenditure and indebtedness
Summary of the 2021 social security report
Furthermore, since 2020, the ONDAM
no longer plays its role of supervising
expenditure, given the exceptional
measures taken to deal with the
pandemic, and in particular the plan
to increase the pay of workers in the
hospital and medical-social sectors, as
well as the exceptional effort to invest
in the health system announced by the
public authorities ("Ségur de la santé") .
Public healthcare expenditure (as a % of GDP)
Source: Eurostat, "General government expenditure by function (COFOG)".
6.0%
6.5%
7.0%
7.5%
8.0%
8.5%
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Germany
Spain
France
Italy
European Union (27)
Sweden
United Kingdom
Share of the crisis and the "Ségur" in the increase in the 2020-2022 ONDAM
Source:
Court
of
Accounts,
according
to
responses
from
the
administrations
Note: expenses with a constant scope during 2020. Under the assumption
of a 2.6% increase in expenditure in 2022 with an unchanged policy
before "Ségur" measures and taking into account the provision planned
in the draft social security finance acts for crisis measures.
2020
2021
€0 bn
€10 bn
€20 bn
€30 bn
€40 bn
€12 bn
€1 bn
€5 bn
€10 bn
€9 bn
€2 bn
€14 bn
€16 bn
€11 bn
€5 bn
€2 bn
2022
Impact of crisis measures
Impact of other Ségur measures
Impact of Ségur salary measures
Increase excluding Ségur and the pandemic
16
Curb social security expenditure and indebtedness
Summary of the 2021 social security report
In addition, financial regulation has
not been accompanied by a sufficient
reform effort, particularly in terms
of the relevance of care and the
transformation of the healthcare
system .
Insufficient relevance and efficiency of care in France: examples
Generics' share of the French
pharmaceutical market (16% by value
and 30% by volume in 2017) remains
low compared to the OECD average
(25% by value and 52% by volume)
and our European neighbours (36%
by value and 85% by volume in the
UK; 35% by value and 82% by volume
in Germany) .
France is one of the OECD countries
w i t h t h e h i g h e s t n u m b e r of
magnetic resonance imaging (MRI)
examinations .
In terms of medical biology, the Court
noted the effectiveness of the price-
volume regulation introduced in
2014 to curb the rise in expenditure
until 2018 . However, based mainly on
price reductions, this system has not
made it possible to control the rise in
volumes .
In hospitals too, a significant
proportion of stays could be avoided .
The difficulties encountered arise
in particular from the lack of a care
solution in downstream structures
or in the home, which are often less
costly for the community .
A link to be established with the
objectives of the national health
strategy
It appears more than ever necessary
to include an ONDAM, redefined in its
scope, in a more formalised regulatory
framework in order to combine, from
a multiyear perspective, compliance
with the financial and health objectives
set by Parliament .
The 2015-2017 ONDAM plan: an interesting precedent
For the 2015-2017 period, a specific
effor t was made to reconcile
financial objectives and the national
healthcare strategy through a
multiyear savings plan known as
the "ONDAM plan" . A retrospective
analysis of this plan, which was not
presented in the budget documents,
shows that the efforts made were
significant, although they fell short
of the initial intentions in terms
of transforming the healthcare
system . It is regrettable that the
public authorities have not learned
from this effort to reconcile the
various objectives from a multiyear
perspective .
17
Summary of the 2021 social security report
Curb social security expenditure and indebtedness
Moreover, in a highly decentralised
healthcare system determined by
supply, controlling expenditure
requires greater accountability of
care providers, both in the outpatient
environment and in hospitals,
particularly concerning the relevance
of care .
Given the multiple healthcare
providers and the challenges of
properly allocating resources
within the healthcare system, it is
necessary to develop and mobilise
more broadly in a coherent manner
all of the available regulatory tools
(tariffs, funding allocations, activity
authorisation, agreements and
contracts with healthcare providers) to
guide healthcare activities at the most
relevant level – national or local as
applicable – to ensure compliance with
the financial and health objectives set
by Parliament .
9.
Broaden the scope of the ONDAM
to include all healthcare expenditure
covered by the social security
branches and attach to it a limited
number of additional objectives
(ministry for social security and
health, ministry for the budget) .
10.
Make the ONDAM part of a
well-documented multiyear trajectory,
documented in depth in connection
with the healthcare strategy, and pre-
cisely justify any revisions relative to
this trajectory (ministry for social secu-
rity and health, ministry for the budget) .
11.
Link a significant portion of the
remuneration of healthcare providers
in the outpatient environment and
hospitals to the achievement of
relevant objectives and formalise
a practice observation mission
combining the expertise of the
national health insurance fund
(CNAM) and the national authority
for health (HAS), notably through the
publication of summaries (ministry
for social security and health, CNAM,
HAS) .
12.
Make pay rises conditional upon
compliance with the ONDAM and
place the corresponding amounts in
the reserve each year (ministry for
social security and health, ministry
for the budget) .
13.
Strengthen the tools and
prerogatives of the regional health
authorities (ARS) to apply the
orientations defined at a national
level within the framework of the
ONDAM, taking into account the
necessary rebalancing between
regions, through:
- the development of population
allocations to the various sectors of
care activities .
- regional allocations, created step by
step from the regional intervention
funds (FIR) and mobilised in a
flexible way by the ARS to facilitate
the local transformations of the
dif ferent sec tors of ac tivity
necessary for more effectively
graduated and coordinated care
(ministry for social security and
health, ministry for the budget) .
Recommendations
19
Exiting crisis management
methods
2
Summary of the 2021 social security report
Through three inquiries, the Court
has drawn up initial assessments of
the management of social security
during the crisis . From the payment
of benefits to the recovery of social
security contributions, the easier use
of telehealth tools and the temporary
suspension of the regulation of
expenditure in medical biology,
the measures implemented have
responded to emergency situations .
However, they cannot continue as they
are:
- the social security funds must return
to management methods that take
sufficient account of the levy recovery
and control requirements;
- the use of telehealth must be
refocused to facilitate access to care
and coordination between healthcare
professionals;
- medical biology expenditure must be
regulated again while ensuring better
support for innovative biology acts .
1 - Social security funds during
the pandemic: initial findings
The Court wished to draw up an
assessment – necessarily provisional
– of the pandemic's impacts on the
organisation, functioning, activities
and operational results of the agencies
of the general social security system
that pay social benefits and collect
social security contributions .
Continuity of services preserved
thanks to exceptional measures
The social security funds were
unprepared for the sudden nature
and scale of the first lockdown, and
had to quickly reorganise themselves .
Remote working was the predominant
method of activity throughout
2020 . Over the year as a whole, the
production capacity of most funds did
not fall, despite the exemptions from
paid activity granted during the first
lockdown (temporary absence of a
computer or the ability to connect to
the funds' computer network) .
20
Exiting crisis management methods
Summary of the 2021 social security report
A priority was placed on the continuity
of rights and the service of benefits,
through measures to extend the rights
of several millions of insured persons
and beneficiaries, the redeployment of
the funds' staff
and by the reduction of
controls .
On an annual average, despite their
increase during the first lockdown
(daily allowances in particular), the
social security funds paid benefits in
2020 within normal, sometimes even
improved deadlines, thanks to the
maintenance of rights and the lifting
of certain controls .
Average times (in days) for payment of legal benefits and basic social welfare benefits
by the CAFs in 2019 and 2020
average payment period for legal services 2019
average payment period for legal services 2020
average payment period for basic social welfare benefits 2019
average payment period for basic social welfare benefits 2020
January
February
March
April
May
June
July
August
September
October
November
December
Source: Court of Accounts, according to data from the CNAF
The closure of reception centres
during the first lockdown, the diffi
culty
in accessing telephone reception
services, which were in much higher
demand than in 2019, and the digital
orientation favoured during the
crisis nevertheless affected access
to social security for insured persons
and beneficiaries not well versed in
digital technology .
The performance
of telephone reception declined
significantly at the healthcare and
family branches .
21
Summary of the 2021 social security report
Exiting crisis management methods
During 2020, nearly €200 million of
additional administrative expenditure
linked to the crisis was recorded . A
significant proportion is linked to
the search for cases of contact with
people infected with the virus (contact
tracing) . Health insurance has invested
heavily in this new public health
mission (nearly 20 million people
called at the end of August 2021 in
total) .
Actions to be stepped up to foster
insured persons' use of their rights
The pandemic has enhanced the social
buffer role played by the social security
funds, in particular the family benefits
agencies (CAF), which pay income
support (RSA) and exceptional aid
approved by the public authorities .
However, the duration of the crisis
underlines the need for more active
support for people in difficulty or
individuals with an illness . By devoting
this mission to positive law
3
, the social
security finance act for 2021 calls for
a change of scale in the actions aimed
at identifying people who are not
exercising their rights to benefits or
assistance .
Control mechanisms require a reset
At the same time, while they are
insufficient in normal times in view of
the extent of the risks of errors and
fraud, on-site checks, as well as on
documents, of the situation of those
entitled to rights and benefits, which
were sharply reduced in 2020, must be
relaunched .
The amount of financial losses stopped
by health insurance following litigation
control actions fell by more than half
in 2020 (€127 million, versus €287
million in 2019); these results mainly
correspond to checks initiated before
the pandemic . The health insurance
agency should enhance checks on
billing by healthcare professionals
and relaunch those concerning
activity billed by public and private
healthcare agencies, which is no longer
controlled at all . It is also important
that the health insurance agency, as it
has undertaken, makes the amounts
of compensation for loss of activity
(DIPA) paid to healthcare professionals
under agreement more reliable .
Checks on the CAFs, which were
reduced in 2020, also require wider
deployment in view of the frequency
of errors, both unintentional and
intentional, made by beneficiaries in
their declarations .
URSSAF checks must also be rearmed:
in 2020, their checking actions – all
actions combined – were halved
compared to 2019 and the adjustment
amounts in their favour fell by more
than a quarter (€1 .1 billion versus
€1 .5 billion) . There are still insufficient
efforts to identify short-time working
fraud .
3
New article L . 261-1 of the Social Security Code .
22
Summary of the 2021 social security report
Exiting crisis management methods
Contributors' debts reaching considerable levels
At the end of 2020, unpaid amounts
from private sector employers on
contributions due in 2020 reached
€11 .4 billion (compared to €2 .3
billion at the end of 2019), i .e . a
deferred contributions rate of 4 .5%,
versus 0 .9% at the end of 2019 .
Almost 41% of these employers' 2
million contribution accounts have
deferred contributions .
Out of €15 .1 billion in social security
contributions called in 2020 on
craftsmen, traders and liberal
professions, €6 .2 billion was not
collected by the URSSAF at the end
of 2020 . At the end of 2020, the rate
of deferred contributions therefore
reached 41 .1% of the amounts due,
versus 10 .1% at the end of 2019 . As
the contributions were called in 2020
on a basis of reduced professional
income, in order to ease the cash
flow situation of self-employed
individuals, their 2020 professional
income tax declarations submitted
in May-June 2021 have resulted in
even higher debts to the URSSAF in
respect of 2020 .
In mid-September 2021, the deferred
contributions in respect of 2020 still
reached €6 .6 billion for private sector
employers and €4 .1 billion for self-
employed workers . In 2021, other
deferred contributions accumulated:
at the beginning of September, €4 .9
billion for private sector employers
and €2 .4 billion for self-employed
workers .
The recovery in collection performance
calls for better consideration of the
economic situation of contributors
by the URSSAF . To this end, the
development of new synergies
and cooperation between the tax
authorities and the URSSAF should
be conducted in greater depth so that
the latter can, in particular, utilise on
a large scale the infra-annual data on
sales declared by a large proportion of
contributors in their VAT returns .
Standardise the recovery of social
security contributions
At the end of 2020, the recovery of
social security contributions was in a
very poor situation, mainly due to the
application of very broad measures
on payment deferral or tolerance
concerning late payments .
23
Exiting crisis management methods
Summary of the 2021 social security report
Recommendations
14.
Improve the business continuity
plans of the social security funds
by formalising reference systems
for solutions that can be activated
and by determining a priori the
means capable of guaranteeing an
immediate widespread rollout of
remote working in major situations
of unavailability of premises or
absences (national agencies of the
general social security system) .
15.
Immediately initiate new actions,
based in particular on the use of data
pooled between the social security
funds and with central government
administrations, necessary for all
eligible persons to exercise their
social rights, particularly for the
benefit of complementary solidarity
health insurance and basic social
welfare benefits (national agencies of
the general social security system) .
16.
Adopt on a larger scale the
checks on the billing of healthcare
costs by healthcare professionals
and agencies to the health insurance
agency, as well as checks on the
basis of social security contributions
declared by contributors (ACOSS,
CNAM) .
17.
Use the data available from the
tax administration to refine recovery
actions regarding contributors
(ministry for public accounts, ACOSS) .
18.
To ensure the proper payment
of the compensation for loss of
activity of contracted healthcare
professionals (DIPA), systematically
check that the declarations made
by beneficiaries match the data held
by the administrations that paid the
financial assistance used to calculate
this assistance, and recover all undue
payments (ministry for social security,
CNAM) .
Recommendations
24
Exiting crisis management methods
Summary of the 2021 social security report
2 - Telehealth: tools to use to
coordinate care
Compared to other countries, France
has planned ahead for the emergence
of telehealth rather well, with a legal
framework for its use having been
defined at the end of the 2000s .
Various trials were then undertaken
to seek to assess the improvements
it brings in terms of access to care
in areas lacking medical resources,
or the coordination of healthcare
professionals for patient care .
The
laborious conduct of these trials and
the late registration, in 2018, of remote
consultations for reimbursement
by the health insurance office have
slowed down their development
during the last decade .
Remote consultations: a useful
palliative measure during the
pandemic
In 2020, due to the Covid-19 epidemic,
the lockdowns and the general public's
reluctance to go to the practices of
non-hospital physicians resulted in
the mass use of remote consultations,
with the number increasing from less
than 140,000 in 2019 to 18 .4 million
in 2020 .
Telehealth has been used in
particular to monitor patients with
Covid-19 .
Change in the number of remote consultations (2017 - February 2021)
First
lockdown
Second
lockdown
2017
2018
2019
Jan 20
Feb 20
Mar 20
Apr 20
May 20
Jun 20
Jul 20
Aug 20
Sep 20
Oct 20
Nov 20
Dec 20
Jan 21
Feb 21
5,000,000
4,500,000
4,000,000
3,500,000
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
Source: Court of Accounts, according to data from the SNDS
(in millions)
25
Summary of the 2021 social security report
Exiting crisis management methods
During the pandemic , various
regulatory measures were taken by
the public authorities to facilitate the
development of remote consultations .
As such, in April 2020, a decree
authorised the reimbursement of
remote consultations by telephone
for certain patients who do not have
access to the devices necessary for
video transmission . These exemptions
were thereby extended until 1 June
2021 .
All of the remote consultation acts
have, moreover, been fully reimbursed
by the health insurance office (instead
of 70% according to the conditions
of common law) . Justified, during
the pandemic, by the time needed
for professionals to acquire technical
solutions enabling remote payment
of the user fee by the patient, this
exemption must not last, however,
since there is nothing to justify
telehealth acts being reimbursed
to a higher level than identical acts
conducted in the office of professionals
or in patients' homes .
Telehealth to be used first and
foremost for coordination and access
to care
With a view to gradually exiting the
pandemic, the Court wished to put the
future of telehealth into perspective .
It does not seem desirable to
establish it as an additional method
of conducting acts; on the contrary, its
selective use should be encouraged,
as part of policies for transforming
the supply of care, to contribute to the
coordination of care or better access
to care . People living in areas with a
low density of physicians, detained
patients, residents of medical-social
establishments or patients with
chronic diseases should be the main
beneficiaries of telehealth .
This requires, in particular, appropriate
financing methods, particularly
to contribute to the development
of remote monitoring, support
mechanisms, notably for liberal
professionals, and a definition of the
role of local organisations in telehealth,
whether regional hospital groups, local
hospitals or even coordinated exercise
structures, such as local professional
health communities (CPTS) .
L a st ly, t h e p u b l i c a u t h o r i t i e s
must continue to facilitate the
acceleration of the technical work
making it possible to put healthcare
professionals in touch with each
other and with their patients, and to
exchange the data necessary for the
care provided to patients .
26
Summary of the 2021 social security report
Exiting crisis management methods
Recommendations
19.
Support the development of
telehealth to ensure the coordination
of care by mobilising as a priority the
grouping of regional hospitals (GHT),
local hospitals and coordinated
practice structures and by providing,
in the pricing reform projects,
financing methods other than a fee-
for-service system (ministry for social
security and health) .
20.
Target aid policies for equipping
the ARS and the CNAM on priority
areas and audiences (ministry for
social security and health, CNAM) .
21.
Strengthen the interoperability
of telehealth information systems
by making compliance with national
standards binding and by including in
them interoperability with connected
medical devices (ministry for social
security and health) .
2 2 .
E v a l u a t e t h e e f f e c t s o f
the relaxations introduced by
amendment 9 to the medical
convention in terms of coordinated
care pathways and prior knowledge
of the doctor (ministry for social
security and health, CNAM) .
23.
End 100% coverage (CNAM,
ministry of solidarity and health) and
develop a plan of post-audits on the
billing of remote consultation acts
(CNAM) .
3 - Medical biology expenditure:
efficiency efforts still
insufficient
The medical biology sector underwent
a major reform at the beginning of
the last decade (order of 13 January
2010 and act no . 2013-442 of 30 May
2013) . This reform strengthened
medicalisation, placing under the
responsibility of a biologist (doctor
or pharmacist) all phases of an
examination, from sampling to
providing an interpreted result . It
also submitted all of the laboratories
to an accreditation procedure to
guarantee the reliability of results . At
the same time, the public authorities
encouraged the grouping together of
medical biology laboratories to achieve
productivity gains .
After an initial investigation in
2 0 1 3 , t h e Co u r t c o n d u c te d a
new investigation at the end of
2020-beginning of 2021, which led to
the following findings .
The regulation of spending is not
based on the search for improved
prescription relevance
Until 2019, expenditure was curbed by
a regulatory mechanism of a primarily
financial nature, setting the standard
for the increase in expenditure at
0 .25% per year, in the form of three-
year protocols concluded between the
health insurance agency and medical
biologist unions .
27
Exiting crisis management methods
Summary of the 2021 social security report
However, it was the reduction in the
rating of acts that made it possible to
comply with the expenditure budgets
in 2016 and 2018 . Between 2014 and
2018, these measures represented
more than €440 million in savings .
While direct action on doctors'
prescribing behaviour would be crucial,
in 2019 the health insurance agency
ceased all actions aimed at reducing
the redundancy of examinations
and irrelevant tests . It is essential to
relaunch risk management actions,
based on benchmarks that the HAS
will have to define for common acts
with the highest financial stakes .
In addition, the ability for biologists to
modify the content of examinations
to ensure the relevance of the acts
performed has remained underused
since it came into force in 2013 .
Suspended during the pandemic,
regulation needs to be relaunched
At the end of December 2020, medical
biology expenses in the non-hospital
environment accumulated over the
year (€4 .96 billion) were 51% higher
than in 2019 . This dynamic is largely
due to the widespread use of screening
tests for the SARS-CoV-2 virus .
Faced with this exceptional situation,
with expenditure unrelated to the
epidemic crisis having decreased in
2020, the application of the three-
year protocol concluded in 2019 was
suspended in 2020 . As such, there was
no pricing adjustment in either 2019
or 2020 . It was not until 2021 that the
regulatory mechanism of the three-
year protocol was reactivated, the
CNAM having made pricing cuts, the
principle of which had been decided in
2020 before the start of the pandemic,
for a total amount of €85 million .
In addition, the high level of RT-
PCR test prices, compared to those
elsewhere in Europe, would have
justified making an earlier decision on
reductions . An additional cost of at
least €800 million is attributable to the
late and partial nature of the reduction
measures .
RT-PCR test price in France, Germany and Belgium
€40
€45
€50
€55
€60
€65
France
Allemagne
Belgique
Source: Court of Accounts
28
28
Summary of the 2021 social security report
Exiting crisis management methods
Shortcomings in terms of territorial
regulation, quality and taking
into account innovations in the
nomenclature of medical biology acts
Since 2016, neither the National
Medicines Safety Agency (ANSM) nor
the Regional Health Agencies (ARS)
have received any reports from the
agencies responsible for laboratory
quality control . The ANSM does not
know which laboratories have not
checked themselves . Since 2016, it
has reduced the number of its staff
assigned to this mission six-fold .
The ARS did not put themselves in a
position to ensure, in view of changes
in territorial density, the continuity
of access to biological diagnostic
capabilities . Between 2013 and 2020,
despite the concentration in the
sector, the relative stability of the local
establishments of the sampling sites
resulted in continued inequalities in
access to the independent biology
offering: the areas with the most
laboratories are still the Paris region,
Grand-Est, Nouvelle-Aquitaine and the
PACA region, while under-dense areas
remain the same .
Lastly, while the last decade has
been marked by a continuous flow
of innovations in the field of biology,
the processes for registering for
reimbursement and determining
prices appear insufficiently responsive .
Nearly 700 innovative acts have
been accumulated over more than a
decade, pending evaluations allowing
their possible coverage by the health
insurance agency and the setting of
their reimbursement rates .
Recommendations
24.
As part of the rollout of electronic
prescriptions, ensure compliance
with the obligation for prescribing
physicians to communicate to
biologists the relevant clinical
elements (ministry for social security
and health, CNAM) .
25.
To foster volume control, with
relevance in mind, produce standards
for common examinations with the
highest financial stakes (ministry for
social security and health, CNAM, HAS) .
26.
Reduce the evaluation time by
31 December 2024, by eliminating
acts that have become obsolete or
unnecessary and by integrating the
others into the nomenclature of
medical biology acts (ministry for
social affairs and health, CNAM, HAS) .
2 7 .
M a i nt a i n u p -to - d ate a n d
coordinated data on the territorial
location of laboratories, their
economic situation, and restructuring
and concentration movements with
a view to preserving local biology
(ministry for social security and
health, ministry for the budget,
CNAM) .
29
Relaunch and accelerate
management reform and
improvement projects
3
Summary of the 2021 social security report
The pandemic has slowed the progress
of many management reform and
modernisation projects, which must
be relaunched . It remains particularly
necessary to transform the health
system to ensure better healthcare
for patients, fostering the continuity
of the care pathways, the provision
of care adapted to each individual's
medical situation and taking medical
innovation into account . This also
applies to the controlled development
of digital tools to improve the service
relationship, the effective use of
social rights and the reliability of the
management of social benefits .
The Court illustrates these issues
through the summaries of four
enquiries on adapting the financing
methods of healthcare establishments
and medical-social establishments
and services, paperless medical
prescriptions and improving the
management of certain social security
or solidarity mechanisms, such as
the recognition of and compensation
for work accidents and occupational
illnesses, the solidarity allowance for
the elderly and the back-to-school
allowance .
1 - Follow-up and rehabilitation
care, psychiatric care, reception
of dependent elderly people
and people with disabilities: ten
years of unsuccessful reforms
in the financing of agencies and
services
From 2003, the reform of activity-
b a s e d p r i c i n g ( " T 2 A " ) w a s
implemented in hospitals and clinics,
with each acute care stay in medicine,
surgery and obstetrics (MCO) now
being priced based on the same
medical-economic nomenclature .
The principles of these new funding
rules inspired four major projects
undertaken at the start of the last
decade for the other activities of
health establishments (follow-up and
rehabilitation care, and psychiatric
care), as well as for those of medical-
social agencies and services (ESMS) for
the reception of the elderly (nursing
homes) or people with a disability .
30
Unsuccessful reforms
Convergent findings emerge:
- overall, aside from the elderly sector
(90% of activity-based funding
indirectly), activity's share of funding
remains low: 31% follow-up and
rehabilitation care, 8% psychiatry, 0%
people with a disability;
- with the exception of those used to
assess the medical burden of caring
for dependent elderly people and
which can still be improved, the
pricing tools are not yet sufficiently
medicalised;
- the principles of most projects have
evolved to introduce differentiated
allocation mechanisms for funding
by region and territory, although
these still need to be more firmly
supported;
- the support for and organisation of
the various projects is fragile;
- forward planning regarding the
problem of managing the financial
effects of the reforms is insufficient,
the reform of long-term care
packages for nursing homes had to be
adapted in 2018 to take into account
the difficulties of agencies whose
resources were reduced due to the
application of new rules;
- lastly, the financing reforms are
carried out without sufficient links
with the other tools for transforming
the healthcare system (authorisation
system, target and best efforts
contract, etc .) and they are too often
called upon to support objectives
instead of other drivers that would
seem more appropriate .
An increased cross-sectoral nature
of the management of the various
projects is necessary to ensure a
better response to patient needs . As
patients can successively be handled
by different care sectors, the overall
coherence of the reforms must foster
adapted care, under a rationale of
pathways and gradation, by promoting
outpatient care in particular or home
care .
Relaunch and accelerate management reform
and improvement projects
Summary of the 2021 social security report
31
28.
By the end of 2024, develop,
for each of the fields, the tools for
measuring the extent of coverage
with the aim of enriching the
corresponding pricing models
(ministry for social security and
health, CNSA) .
29.
Extend to the follow-up and
rehabilitation care sector and ESMS
the legislative principle aimed at
gradually correcting territorial
inequalities through the distribution
between regions of allocations, set
according to transparent criteria
(ministry for social security and
health) .
30.
Set up a permanent cross-
sectoral structure of "delegated
project ownership", within the
general secretariat of social
ministries, in charge of supervising
and coordinating pricing reforms
(ministry for social security and
health) .
31.
With a view to achieving more
selective use of pricing incentives,
establish upstream of the reforms
the projected map of the use of the
three main levers for transforming
the offering: authorisations, multi-
year target and best efforts contracts,
and pricing (ministry for social
security and health) .
32.
Adopt a rigorous methodological
framework for financial simulations
and consultations concerning reform
projects and insert them into a pre-
fixed timetable of a reasonable
duration (ministry for social security
and health) .
Recommendations
2 - Medical e-prescription:
a factor in the efficiency of
the health system, ambitious
projects to be completed
The switch to paperless medical
prescriptions could enable major
progress, particularly in terms of
the quality and safety of care, the
relevance and efficiency of health
expenditure, the reduc tion of
management costs and the prevention
of errors and fraud .
Relaunch and accelerate management reform
and improvement projects
Summary of the 2021 social security report
32
Examples of the expected progress from e-prescriptions
E-prescriptions will make it possible
to put an end to the difficulties
stemming from the paper format of
medical prescriptions: loss, damage
and reading difficulties, which can
cause medication errors .
T h e y c o u l d e n c o u r a g e t h e
development of prescriptions of
drugs with a non-proprietary name,
in principle mandatory, and of generic
drugs, with France lagging behind in
this area (one in three boxes issues,
versus four in five in the United
Kingdom) . To e-prescribe, doctors
will have to use prescription support
software .
These will eliminate certain risks of
fraud and errors: the absence of an
effective prescription, the surcharge
or reuse of a prescription several
times in several different pharmacies,
the backdating of prescriptions and
discrepancies between billing by
health system stakeholders relative
to prescriptions .
They will enable the health insurance
agency and healthcare professionals
to achieve productivity gains on
administrative tasks .
Relaunch and accelerate management reform
and improvement projects
A lot of ground to make up
Currently, the health insurance
agency offers e-prescription remote
services only for sick leave and patient
transport . They are still underused .
Most medicine prescriptions have
switched to paperless in Belgium,
Spain, Italy and the United Kingdom, in
some cases several years ago, while in
France they are still only paper-based .
France is aiming to catch up in
e-prescriptions . Pursuant to the law
of July 2019 on the organisation and
transformation of the healthcare
s y s te m , d o c t o r s w i l l h av e t o
e-prescribe sick leave by the end of
2021 and all other prescriptions by
the end of 2024 . However, only part
of the implementing texts have been
adopted to date .
The risk of e-prescriptions in a non-
optimal scope and mode
However, these timetables seem very
ambitious . In the first half of 2021,
just 54% of notices for sick leave and
maternity leave issued by non-hospital
physicians were paperless . Following
trials, the health insurance agency
must set up new e-prescription remote
services from 2022 and non-hospital
and hospital physicians must adapt in
order to use them .
Medicine prescriptions could switch
to paperless fairly quickly, although
in a non-optimal mode that would
not enable much of the expected
progress to materialise (see inset):
lack of codification of the dosage and
duration of the prescription or use
of the international non-proprietary
name, with the trade names remaining
Summary of the 2021 social security report
33
Relaunch and accelerate management reform
and improvement projects
in use; lack of interoperability of the
software used by various healthcare
professionals limiting the services
offered to patients .
While hospital prescriptions fulfilled
in the non-hospital environment
(PHEV) represent a significant part of
non-hospital spending (22% in 2019),
prescriptions for sick leave at the end
of a hospital stay are not subject to the
e-prescription obligation . Obstacles
c o u l d h i n d e r t h e c o m p u l s o r y
e-prescription of other PHEVs: the
lack of authentication of effective
prescribers and the lack of connection
of hospital information systems to
the health insurance agency's
e-prescription remote services .
According to the texts in force, taxis
and service providers and distributors
of medical devices will not be required
to send to the health insurance agency
e-prescriptions issued by doctors .
3 3 .
E x te n d t h e s co p e of t h e
obligation to digitise prescriptions
to all healthcare acts, goods and
products prescribed and performed
or dispensed by all stakeholders
in the health system in the non-
hospital environment and hospitals,
by remedying several omissions
(sick leave prescribed in healthcare
agencies, transport by approved taxis
and medical devices marketed by
service providers) (ministry for social
security and health) .
3 4 .
A d o p t n o n - c o m m e r c i a l
references for the e-prescription
of medicines and medical devices
and define methods for codifying
the paperless prescriptions for acts
involving biology, paramedics and
other doctors (ministry for social
security and health, digital health
agency, CNAM) .
35.
As part of the programme
that will take over from Hop'en in
2023, guarantee the connection
of hospital information systems to
the e-prescription services set up
by the health insurance agency and
effective individual authentication of
professional prescribers in hospitals
(ministry for social security and
health, CNAM) .
Recommendations
Summary of the 2021 social security report
34
3 - Recognition and
compensation for work
accidents and occupational
illnesses: a complex system that
needs to be modified
For the 18 .8 million employees
affiliated with the general social
security system, the work accidents-
occupational illnesses branch
(known as the "AT-MP branch")
covers, according to complex rules,
the consequences of incidents
recognised as being occupational in
origin .
Recognition of the link with
work usually takes place based on a
simple presumption of liability without
fault of the employer, which exempts
the employee from establishing a
fault of the employer and a causal
link with the damage suffered .
In
return, the law provides for fixed and
partial compensation for the damage
suffered by the worker, funded
exclusively through contributions paid
by employers .
In 2020, the AT-MP branch recorded
€13 .4 billion in expenses, mainly
relating to temporary incapacity
and permanent inability to work .
The healthcare costs, which are
fully covered by the AT-MP branch,
are imperfectly identified, with some
proving to be unduly borne by the
healthcare branch .
Relaunch and accelerate management reform
and improvement projects
Services provided by the AT-MP branch (in €m)
AT-MP allowances
Sick leave
Healthcare expenditure
Source: Court of Accounts, according to the annual financial statements.
Summary of the 2021 social security report
35
Relaunch and accelerate management reform
and improvement projects
Two main findings were drawn up by
the Court of Accounts .
Insufficient priority placed on actions
enabling temporarily incapacitated
employees to return to work
Unlike most European countries (there
are many examples: Switzerland,
Germany, Sweden, Denmark, Austria,
etc .), the compensation is mainly
financial . It has little to do with
helping victims of work accidents
or occupational illnesses return to
work . This long-standing observation
is still valid because of a lack of
coordination between public and
medical stakeholders (ministry of
labour, occupational medicine, ministry
of health, health insurance agency,
general practitioners), with businesses
not involved to any significant degree .
However, there are two issues at stake:
the interests of individuals – through
the restoration of their ability to work
– to maintain their employability
over the long term and the control of
expenditure on compensation for sick
leave, which is particularly dynamic .
A management characterised by some
conservatism, which perpetuates a
great deal of complexity
The framework for managing the
recognition of occupational illnesses
is in dire need of flexibility, with an
abundant system of committees
that does not foster the necessary
changes to the "tables of occupational
illnesses" . The case of musculoskeletal
disorders (MSDs) illustrates this
situation . In France, they account
for 85% of recognised occupational
illnesses, which is a very unusual
figure compared to other European
countries .
The atypical application of the principle of presumption to MSDs
Overall , per 100,000 insured
individuals, 258 occupational
illnesses are recognised in France,
v e r s u s 8 1 i n G e r m a n y . T h i s
difference is mainly due to the
implementation, in France, of the
principle of presumption through the
tables for diseases whose causes are
nevertheless multi-factor, particularly
for MSDs (such as lower back pain
and carpal tunnel syndromes); 227
cases are recognised in France per
100,000 insured individuals, versus
just 4 in Germany .
Summary of the 2021 social security report
36
Relaunch and accelerate management reform
and improvement projects
Summary of the 2021 social security report
Recognition of occupational illnesses (by number of illnesses)
MP total
MSD total
Asbestos total
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
Source: The health insurance agency – Occupational risks, 2019 annual report
The determination of the permanent
incapacity rate, which is used to
calculate the allowances paid to
people who still suffer from significant
after-effects, must be revised, both by
updating the regulatory scale but also
through management instructions
given to the medical advisors of the
health insurance agency (for some
conditions, e .g .
chronic respiratory
conditions, an extremely wide range
of incapacity rates attributed ranging
from 10% to 100% was found) .
L a s t ly, t h e m o d e r n i s at i o n of
administrative management deserves
to be accelerated in many respects:
the allocation of pensions must
be optimised to avoid disrupting
resources for the insured persons
concerned; the use of paperless
procedures must become the norm
(medical certificates, work accident
declarations, sick leave notice); the
data from the nominative social
declaration (DSN) must be able to
be used to determine the base of the
allowance; teams from the medical
service must be grouped together
in specialised centres with those of
the primary funds to improve the
management of the recognition
of occupational illnesses and the
management of allowances .
37
Relaunch and accelerate management reform
and improvement projects
Summary of the 2021 social security report
36.
Control and improve the methods
of charging healthcare costs to the
AT-MP branch (ministry for social
security and health, CNAM) .
37.
Accelerate the necessar y
adaptations of the existing tables of
occupational illnesses by providing in
particular for their implementation
by a decision of the Director General
of the CNAM after consultation with
the AT-MP commission (ministry
for social security and health,
Secretary of State for pensions and
occupational health, CNAM) .
38.
Standardise, notably through a
change to the scale, the determina-
tion of the incapacity rate and the
listing of situations likely to justify the
application of a professional coeffi-
cient (ministry for social security and
health, CNAM) .
39.
Make the support for return-
ing to work more effective through
early intervention with employees,
in conjunction with their attending
physician, by involving the employ-
er and the occupational health ser-
vices (ministry for social security
and health, Secretary of State for
pensions and occupational health,
CNAM) during the sick leave .
Recommendations
4 - The basic old-age
pension and the back-to-
school allowance: a strong
contribution to poverty
reduction, mixed management
performances
The basic old-age pension, allocated
since 2007 in the form of the solidarity
allowance for the elderly (ASPA),
and the back-to-school allowance
(ARS), created in 1974, are two non-
contributory solidarity mechanisms,
significant both in terms of the
number of beneficiaries concerned
(750,000 elderly households and three
million families) and the increasing
amounts provided, supported by the
social security system (respectively
€3 .9 billion and €2 .6 billion in 2020) .
The Court considered it interesting
to conduct a descriptive comparative
analysis of these two mechanisms .
38
Relaunch and accelerate management reform
and improvement projects
Summary of the 2021 social security report
Two allowances designed to provide additional resources to households and
families on very low or modest incomes.
The main rules for allocating the ASPA
The beneficiary must have liquidated
their pension rights, be 65 years
of age or over (62 in the event
of inability to work or permanent
incapacity of at least 50%) and
legally reside in France for at least six
months per year .
The allowance takes into account all
of the household's resources (except
housing allowances) . It is referred
to as differential, being equal to
the difference between household
income and the cap on the allowance
(€906 .81 or €1,407 .82 for a couple
as of 1 January 2021) . The basic
old-age pension allowances result
in a recovery being claimed on the
beneficiary's estate from the heirs
or beneficiaries for the proportion of
the inheritance exceeding €39,000
(€100,000 overseas) . The amount of
the recovery is capped at €7,354 .12
per year for a single person and
€9,838 .68 for a couple .
The amount of the ARS varies
depending on the age of the children
(€370 .31 for primar y, €390 .74
for middle school and €404 .28 for
secondary school) . The allowance is
subject to means testing .
The caps are set according to the
number of children, but are unrelated
to the number of working people in
the family . They are higher, for couples,
than the floors corresponding to the
so-called poor and working-class
income classes, and average for single-
parent families .
Two regularly upgraded mechanisms
helping to reduce poverty
The basic old-age pension and the
ARS are indexed to inflation . However,
the former has been exceptionally
revalued (50% increase between
2005 and 2020) and the latter saw an
exceptional increase of €100 in 2020 .
The poverty rate for retirees aged 65
and over, defined as the proportion
of people with a standard of living
below the poverty line, among retirees
aged 65 and over was 8 .7% in 2018,
a significantly lower rate than among
the general population (14 .8%) .
Among the eight European countries
studied, the poverty rate for people
aged 65 or over is the lowest in France
(more than ten points lower than the
poverty rate for those under 18) .
The ARS also helps to reduce the
precariousness of low-income families .
According to the national family
allowance fund (CNAF), it decreased
for its beneficiaries, by 2 .5 points in
2019, the proportion of those living
below the poverty line, thereby
39
Relaunch and accelerate management reform
and improvement projects
Summary of the 2021 social security report
lowering it from 41 .2% to 38 .7% . It
is one of the most generous back-to-
school assistance schemes among
those introduced by OECD countries:
relative to the minimum wage, the
amount of aid is among the highest in
France, representing a quarter of the
amount of the gross minimum wage,
versus 10% in Germany .
However, changes to the systems are
desirable
The rules for allocating the basic old-
age pension, which are very complex,
should be simplified, which would
make it possible to reduce the causes
of errors and fraud .
ASPA: a high error rate
The frequency of errors continued
to increase in 2020, reaching 23 .8%
for the ASPA . As such, nearly one
in four liquidations included at
least one error causing a financial
impact, at the beneficiary's expense
in 75% of cases . Almost three
quarters of fraud detected in the
old age branch concern the basic
old age pension, mainly for breach
of residence or resource conditions,
the management bodies of which
stress the complexity and difficulty of
conducting checks .
This simplification would also make it
possible to facilitate the provision of
information to the public, as a large
proportion of people do not exercise
their entitlement to the allowance .
According to a study by the national
old-age insurance fund (CNAV), the
rate of non-use was between 34% and
49% depending on the assumptions
used . Direct questioning of 350 of
these insured individuals showed that
three quarters of them could claim the
ASPA and that half did not know about
this system or were not very familiar
with it .
The ARS: a mechanism whose
management must remain simple
However, the ARS amounts are weakly
modulated according to children's age .
All of the available studies show that
the expenditure increases significantly
alongside the level of schooling,
var ying from single to double
between a primary school pupil and a
secondary school student . The benefit
of the back-to-school allowance could
therefore be refocused on families on
the lowest incomes and the scale of
the back-to-school allowance would
also benefit from being adjusted, at
a constant cost, to more effectively
cover expenses related to the
education of older children .
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Summary of the 2021 social security report
On the solidarity allowance for the
elderly:
40.
More effectively integrate
the specific characteristics of
the A SPA into the def inition
and implementation of internal
control systems and measure their
effectiveness through a specific
residual risk indicator, the analysis
of which will improve the quality
of liquidation (ministry for social
security and health, pension funds) .
41.
Draw on the data analysis to
identify potential beneficiaries of the
ASPA and strengthen information
actions aimed at them, with the
aim of reducing the rate of non-use
(ministry for social security, pension
funds) .
42.
Undertake a project to simplify
the rules governing the ASPA and
step up work on the digitisation
and automation of its management
processes (ministry for social security
and health, FSV, pension funds) .
On the back-to-school allowance:
43.
As soon as possible, use the
monthly resources system (DRM) to
allow more recent resources than
those of year Y-2 (CNAF) to be taken
into account .
44.
Study, for the sake of consistency
and simplification, the abolition of
the tax reduction for tuition fees
in secondary education and the
redeployment of the expenditure, at
a constant budgetary cost, to adjust
the amounts of the ARS awarded to
middle school and secondary school
students from low-income families
(ministry for social security, ministry
for the budget) .
Recommendations