Sort by *
A -
Thanks to both standard and supplementary health insurance,
patient out-of-pocket expenses are lower than anywhere else in
B -
The financial balance of health insurance is affected by
structural factors: the ageing population and the increase in
chronic illnesses
C -
The direct and indirect effects of the health crisis have been to
create the risk of a profound and lasting deficit in health insurance
A -
Health system stakeholders must be better organised in line
with the objectives of accessibility, continuity, quality and safety of
B -
Remuneration of stakeholders in the health system must be
reformed in order to reduce economic rent, improve quality of care
and slow increases in the most dynamic expenditure
C -
Preventable sources of health expenditure and health insurance
costs should be resolutely reduced
Under certain conditions, digital technologies can improve
efficiency in the health system and health insurance expenditure
This policy paper is part of a body of work intended to present, on several major public
policies, the main challenges that public decision-makers will face in the coming years and the
levers that could make it possible to meet those challenges. This series of publications, which
runs from October to December 2021, is a follow-up on the June 2021 report submitted to the
President of the Republic, entitled, Exiting from crisis: A public finance strategy. That paper
identifies structural issues, it offers a diagnostic resulting from previous works by the Court as
well as guidelines for long-term growth, while strengthening the equity, effectiveness, and
efficiency of public policies.
The Court, in accordance with its constitutional mission of informing citizens, wished to
develop a new approach, one that is different from its usual work, and thus contribute, through
this series of deliberately concise and targeted documents, to the public debate, while taking
care to leave open various possible avenues for reform.
This report was deliberated by the 6th chamber and approved by the Court of Accounts'
Publication and Planning Committee.
Publications of the Court of Accounts are accessible online on the website of the Court
and the regional and territorial chambers of accounts:
In structural terms, the financial stability of the health insurance system has been
affected by the ageing population and an increasing share of chronic pathologies in health care
expenditure. In addition, the impacts of the health crisis on social security receipts and the
increases in remuneration paid to health system stakeholders
determined in particular within
the framework of the "Ségur de la santé" agreements
risk creating deep and lasting deficits
in the health insurance sector.
While health expenditure and the portion of its funding shared by health insurance are
at high levels in France compared to most other European countries with a high level of social
protection, the priority issue is one of controlling health costs. Because today’s policy of
financing social spending through borrowing shifts the burden onto future generations, the
Court is calling for health insurance to return to a sustainable financial balance by leveraging
the very significant potential efficiency gains that exist in four areas: the organisation of care,
the remuneration of health stakeholders, avoidable causes of expenditure and the contribution
of digital technologies to the transformation of the health system.
Key figures:
Current health expenditure (in the international sense):
270 billion
; i.e. 11.1% of
GDP, including consumption of medical care and goods:
208 billion
; i.e. 8.6% of
GDP (2019). 78% of this consumption of medical care and goods is covered by health
Percentage of the population residing in France in a stable manner and in good
standing and whose health expenses are covered by compulsory basic health
Percentage of the population with supplementary health cover:
96% (2019).
A few average annual costs of pathologies: more than
for chronic dialysis
(55,000 people), more than €
12,000 for active cancer (1.5 million people), €
9,700 for
acute heart failur
e (655,000 people), more than €
2,700 for diabetes (4 million people).
In 2020,
11.6 million
people insured under the general scheme (i.e. almost one in
five) were suffering from chronic illness, with an average age of
63 years
The covid 19 health crisis is a reminder of the precious nature of the collective and
individual resource of health.
In order to remove financial obstacles to access to care, health insurance mutualises
the financing of a major portion of health expenditure within the national framework. Health
insurance reimbursements benefit anyone with a current or past professional activity, or
residing in France in a stable manner and in good standing. They are almost entirely (96%)
paid by third-party payers to healthcare professionals and establishments, which also receive
lump-sum allocations and remuneration, unrelated to the level of their activity.
Although not the only contributory factor, the health insurance-financed healthcare
system makes a decisive contribution to the health of our fellow citizens: in 2019, life
expectancy at birth was nearly 86 years for women and 80 years for men, compared to almost
65 and 60 years in 1946. However, the effects of the ageing population and chronic pathologies
on health expenditure are having an impact on the financial sustainability of health insurance.
At the end of the health crisis, the deficit could reach especially high levels.
Having emphasised the role and the financial position of health insurance (I), the Court
stresses the importance of the efficiency savings which are intended to be introduced in order
to ensure a lasting return of health insurance to a state of financial equilibrium (II).
In France, spending on health is among the highest among European countries with a
high level of social protection (see inset). Thanks to both standard and supplementary health
insurance, average patient out-of-pocket expenses are low. Driven by the direct and indirect
consequences of the health crisis, there is a danger that health insurance may experience a
high and lasting deficit.
A clear financial emphasis on health in France
In 2019, health expenditu
re in France stood at nearly €
270 billion, which
to the international definition of current health expenditure (an aggregate figure including the
consumption of medical care and goods, expenditure on long-term care in medical, social and
preventive establishments and health system governance organisations)
represented 11.1%
of gross domestic product (GDP). In Europe, France is outstripped only by Germany (11.7%)
and Switzerland (11.3%) and is ahead of the Nordic countries, Belgium, the Netherlands and
Graph no. 1: health expenditure as a % of GDP in a pool of European countries in 2019
Source: Court of Accounts, based on data from the Organization for Economic Co-operation and Development (OECD)
A. Thanks to both standard and supplementary health insurance,
patient out-of-pocket expenses are lower than anywhere else in
1 - Health insurance covers almost 80% of health expenses
According to the health accounts established by France’s Ministry of
Health, the
consumption of medical care and goods amounted to €
208 billion in 2019.
Compulsory health insurance (sickness and occupational accident branches
occupational illnesses from social security) financed 78% of this expenditure, i.e. €
162 billion:
healthcare in the strict sense, health products (drugs and medical devices, ranging from
dressings to medical beds at home, including oxygen therapy) and services (patient transport)
delivered by contracted city professionals (doctors, dental surgeons, medical auxiliaries,
including nurses with a state qualification, physiotherapists and orthoptists, pharmacists,
suppliers of medical devices, biological analysis laboratories, health transporters and
contracted taxis) and health establishments (public, private not-for-profit and private-for-profit).
In total, health insurance in the broad sense (branches for sickness, accidents at work
occupational medicine and health and independent living for social security) paid out €
billion in net expenditure in
2019, including €
217 billion in social benefits, €
6 billion in
transfers, including to State public establishments, and €
8 billion in administrative
management expenses.
Annual social security finance acts set a national healthcare expenditure objective
(ondam), the aim of which is to control changes in expenditure over time. This objective covers
most expenditure on benefits and transfers for the sickness, occupational health and
independent living branches. It includes not only expenditure, but also revenues which serve
to reduce this expenditure (in particular the rebates paid by the pharmaceutical companies on
the public sale prices of the drugs). For 2019, recorded ondam expenditure amounted to just
over €
200 billion, including €
91 billion for non-hospital care (mainly drugs, medical devices,
medical, dental and paramedical fees, biological analyses, patient transport and daily
allowances for illness and occupational health), €
83 billion for healthcare establishments and
21 billion for medico-social establishments and services.
2 - Supplementary health insurance nevertheless plays an important
and much-debated role
Private supplementary insurance, plus a public system
supplementary social health
also contributes to reducing patient out-of-pocket expenses by reimbursing a large
part of the expenses not reimbursed by health insurance.
In 2019, the supplementary insurance offered by mutuals, insurance companies and
provident institutions covered 13% of the consumption of medical care and goods, i.e. €
billion in expenditure: ticket modérateur co-payments applied to the reimbursement base for
sickness insurance (there are 7 distinct rates, from 20% to 85% depending on the expenses
concerned); overruns on medical and dental fees, dental prostheses, hearing aids and glasses
over and above the health insurance reimbursement base; daily hospital fee; expenses not
reimbursable by health insurance (such as a private room in the hospital).
The State regulates the terms under which supplementary insurance applies in order
to reduce the health costs remaining payable by patients and to curb inflation for certain
expenses. To take advantage of reductions in social contributions and taxes on the sums they
pay to insurance, employers of staff, self-employed workers and individuals are required to
take out contracts that are solidaires (contributions are not dependent on the insured person’s
health) and r
esponsables (the contract encourages compliance with the insured person’s
coordinated care pathway). Since 2014, such contracts have been required to cover a wide
range of expenses: all co-payments, except for medicines offering only a marginal
improvement in the medical care provided and spa treatments; the full daily hospital charge,
without time limit. They set minimums for certain items (glasses and dental and hearing aids),
as well as coverage ceilings (excess fees and glasses).
Since 2016, employers of employees have been required to take out supplementary
health insurance on behalf of their employees, which must be
solidaire and responsable
, and
finance at least half of the cost of the cover (which is an average of nearly 60% in practice). A
ruling of February 2021 requires employers to pay half the cost of the cover by 2024 for the
State civil service and by 2026 for regional and hospital functions.
Nevertheless, supplementary health insurance companies charge their subscribers
management fees, the
amount of which (€
8 billion in 2018, including 40% for the acquisition
of new customers) exceeds the value of the health insurance funds for reimbursements six
times lower. The aforementioned subscription aids come at a high cost for government
finances (
an approximately €
7 billion reduction in tax and social security receipts). Apart from
employees, the ratio between the cost of the cover and the level of reimbursements is not very
attractive, especially for the elderly (charges increase sharply with age).
Instead of taking out insurance contracts, households with low incomes can ask their
health insurance fund for support from the supplementary social health insurance (CSS), which
in November 2019 replaced supplementary universal health cover, created in 2000. In 2019,
CSS financed more than €
2 billion in expenditure, i.e. 1% of the consumption of medical care
and goods.
The purpose of the CSS is to leave no patient out-of-pocket expenses: full coverage of
co-payments and daily hospital charges, application of special pricing for expenditure on
glasses and dental and hearing prostheses, and a prohibition on fee overruns. However, these
obligations are not respected by some professionals unless penalties are applied.
Beneficiaries of the CSS also enjoy an exemption from the flat-rate contributions and
deductibles payable by other social insured persons, and also enjoy a general advance waiver
for their health costs. Depending on the level of their household’s resources, the CSS is
allocated to them either free of charge or in return for a contribution that is less expensive than
private insurance.
The CSS now covers more than one person in nine. In order to reduce the non-use of
this right, the social security finance bill for 2022 provides for automatic allocation to
beneficiaries of the active solidarity income and the minimum old age, unless they object.
Debate over the link between health insurance and private insurance
The link between health insurance and private insurance is currently the subject of
debate. There are several possible ways forward:
to maintain the current division between health insurance and supplementary
insurance, accompanied by increased regulation in this area
: this would involve reducing
the cost and inequality of supplementary insurance by improving the currently insufficient
transparency of the offerings, if necessary by introducing a standardised way of presenting
them, promoting competition between organisations by means such as making their offerings
more comparable, and regulating their management costs, e.g. by capping their level relative
to the level of reimbursements;
to establish a “
health shield
: the out-of-pocket costs following the application of
health insurance would be capped according to the income of the insured persons and, where
applicable, the existence of a long-term condition, as is the case in Germany or Belgium. By
preventing excessive out-of-pocket payments, this system would reduce the need for
supplementary health insurance cover. In order to be financially sustainable for health
insurance, it should be offset by a reconsideration of the 100% coverage of a large portion of
health insurance expenditure, including chronic illnesses. This would result in significant
redistributions between beneficiaries of social insurance;
a separation of the respective fields of health insurance and private insurance
health insurance would cover certain expenses in full, including existing
ticket modérateur
payments, depending on their nature (primarily hospitalisation) or the income of social
insurance beneficiaries, in order to preserve access to care; meanwhile, health insurance
private companies would likewise fully finance other expenses starting from the first euro. Such
a disentanglement of the services of health insurance and private insurance would put an end
to overlaps between their management costs for the same health expenditure reimbursement
If the scope of health insurance were to be expanded (the proposed “
grande sécurité
” system), the
share of private insurance in the financing of health expenditure would
be significantly reduced. However, public expenditure and levies would increase, despite the
fact that the increase in public levies would be mitigated by the abolition of tax and social
assistance for insurance cover. On average, insured persons not taking out private insurance
probably accounting for the majority
would face an increase in public deductions that was
lower than the payments they are at present making to their supplementary health insurance:
such payments currently include not only reimbursements of health expenses, which would be
covered by health insurance, but also the management costs for supplementary health
insurance, which they would no longer be taking out.
This rough prediction of the impacts of an extended scope of health insurance cover
could, however, conceal significant disparities in situations between insured persons. In
addition, it matches the situation that would immediately result from the shifting of the financing
dividing line between health insurance and private insurance. In fact, without private insurance,
most households could only sustainably manage to cover part of their health costs on two
conditions: (1) tighter control over the health expenses covered by health insurance,
preventing any subsequent reduction of its scope, by removing reimbursement of expenditure
or dissociating the accepted pricing from the charges which it would cover in full; or (2) strong
regulation of the accepted level of excess fee rates, which by definition are not covered by
health insurance.
3 - Patient out-of-pocket expenses are falling, and are lower
than anywhere else in Europe
In 2019, out-of-
pocket expenses payable by patients, i.e. €
15 billion, represented 8%
of the consumption of medical care and goods. The relative proportion of out-of-pocket costs
has fallen continuously since 2008
a year in which they reached 9% of medical care and
goods expenditure
following the introduction of flat-rate contributions and deductibles
payable by persons covered by social insurance who were not insurable by supplementary
health insurance.
On average per inhabitant, expenses for medical care and goods payable out of pocket
by patients after health insurance support were
of the order of €
670, and €
210 after
supplementary health insurance support. While supplementary insurance and supplementary
social health insurance now cover 96% of the population, the high out-of-pocket costs that
continue to be observed for some patients have three possible causes: the absence of
supplementary cover; subscription to insurance contracts whose cover is lower than the cover
provided by contrats solidaires et responsables; treatment or goods (dental or hearing aids,
glasses) whose cost easily exceeds the variable level of the cover taken out under these
France is the European country in which patients incur the lowest out-of-pocket
expenditure: in 2019, such expenditure accounted for 9% of current health expenditure in the
international sense.
Graph no. 2: share of healthcare expenditure paid as patient out-of-pocket expenses in
a pool of European countries in 2019 (as %)
Source: Court of Accounts, based on OECD data
Although supplementary insurance is a contributing factor, this low level of out-of-
pocket expenditure in France is primarily the result of high levels of public financing, provided
essentially by health insurance and by supplementary health insurance: nearly 80% of day-to-
day health expenditure in the international sense is publicly funded, a level slightly below that
of most Nordic countries, and identical to that of Germany.
B. The financial balance of health insurance is affected by structural
factors: the ageing population and the increase in chronic illnesses
The trend is towards an increasing share of expenditure linked to chronic illnesses in
health expenditure and, to an even greater extent, in health insurance expenditure.
This development reflects a powerful demographic factor: while the need for care
generally increases with age, the elderly represent a growing proportion of the French
population as a whole as a result of the tendency for lifespans to increase and the birth rate to
decline; people aged over 75 have thus gone from constituting 3.4% of the total population in
1946 to 5.7% in 1980, 7.2% in 2000 and 9.6% in 2020.
It is also a consequence of the audience targeted as a priority by financial health
insurance; in cases where the health insurance acknowledges the existence of a chronic
condition in an insured person, it covers all the expenses related to this illness, including co-
payments. In 2020, 11.6 million people insured under the general scheme (i.e. almost one in
five) had chronic conditions, with an average age of 63 years. Individuals receiving a disability
pension and pregnant women or women who have just given birth to a child are also exempt
from co-payments for all expenses, as are individuals who have suffered an accident at work
or an illness in relation to the associated expenses.
Chronic illnesses have a very significant impact. Firstly in human terms: in 2019, 5
million people suffered from cardio-neurovascular diseases, 4 million from diabetes and 3
million from cancer (in some cases, from several of these pathologies at the same time). Their
number is constantly increasing, assisted by the effectiveness of care, such as often-expensive
drug treatments which postpone the end of life, but also by the appearance of such diseases
in new patients. And secondly, in financial terms: in 2019, nearly two thirds of the value of
health costs reimbursed by health insurance related to patients with chronic illnesses.
Before the implementation of cost-saving measures, the spontaneous increase in
health insurance expenditure often exceeds the increase in income from social security
contributions (contributions and CSG tax) and taxes (VAT, tax on wages and duties on
tobacco) allocated to funding them. This tends to increase the deficit in the healthcare branch
of social security.
C. The direct and indirect effects of the health crisis have been to create
the risk of a profound and lasting deficit in health insurance
Following a long process of recovery in terms not only of expenditure but also in
revenue, health insurance was starting to reach financial equilibrium on the eve of
the health crisis
Health insurance had been in deficit even before the economic recession of 2009
prompted by the financial crisis of 2008. Like the other branches of social security, it suffered
the negative impact of this recession on its revenue. 2011 onwards saw a slow process of
Graph no. 3: change over time in deficits for the general social security scheme (and
the FSV age support fund) and for the healthcare branch within it between 2008 and
2019 (as %)
Source: Court of Accounts from the accounts of the branches of the general social security scheme and the FSV
age support fund
This financial upturn in the healthcare branch of social security was made possible by
increases in compulsory levies in support of social security schemes between 2011 and 2015
(around €
27 billion), channelled largely towards the healthcare branch , as well as by the
redeployment of revenue from other divisions in support of the healthcare branch. It was also
the result of an effort to slow down the rise in health insurance expenditure. As shown in the
graph below, from 2010, the Social Security Financing Laws (LFSS) set more stringent ondam
expenditure objectives than in the past.
Graph no. 4: change over time of expenditure falling under the ondam expenditure
objective as an annual % between 2001 and 2019
Source: Court of Accounts, based on data from F
rance’s Commission des comptes de la sécurité sociale
Between 2010 and 2019, the targets set were more or less achieved each year. Given
the tightening of the ondam until 2018, the share of current health expenditure in the
international sense in relation to GDP fell slightly in 2017 and 2018. In 2019, it stood at 11.1%
of GDP, compared to 11.5% of GDP in 2014.
In 2019, prior to the outbreak of the health crisis, the healthcare branch of social
security was approaching a point of equilibrium, with its defic
it reaching €
1.5 billion.
Given the decisions made by the public authorities during the health crisis,
health insurance now seems a long way from financial equilibrium
for a considerable time to come
Even before the health crisis, the financial equation of the healthcare branch of social
security was already a difficult one to balance. As a result of the health crisis, the healthcare
branch will have lower revenues and much higher expenditure.
Firstly, the health crisis caused the social security system to lose considerable revenue
in 2020. Despite the strong rebound in economic activity in 2021 and the forecast of high
growth in 2022, some portion will probably be lost forever.
Secondly, the public authorities are embarking on an unprecedented effort to increase
remuneration for personnel in health and medico-social establishments, and also to finance
their investments and the increasing use of digital technology: the “Ségur de la santé”
agreements signed in July 2020 and other measures to extend them will lead social security
to incur an additional €
13 billion in expenditure in 2022 compared to the pre-crisis period; i.e.
0.5% of gross domestic product, including nearly €
10 billion in wage increases (€
7.7 billion
for healthcare establishments and €
2.2 billion for the medico-social sector). Other decisions,
also of a long-term nature, benefit healthcare establishments and healthcare product
companies (establishment of multi-year expenditure increase objectives) and community
medicine (amendment no. 9 to the medical agreement of 2016).
Between 2019 and the 2022 forecast in the LFSS social security financing bill for 2022,
ndam’s expenses
excluding those directly linked to the health crisis
grew at an
accelerated rate, rising from €
200 billion to €
231 billion (+15.5%).
As shown in the graph below, the healthcare branch recorded a massive deficit in 2020
30.4 billion), which represented the largest part of the social security deficit (€
38.7 billion
for the general scheme and the FSV age support fund), in a price scissors effect combining
falling revenues and expenditure increased by the crisis (including tests, purchases of personal
protective equipment and additional operating costs for establishments). According to the
forecasts in the LFSS bill for 2022, this deficit will reduce between 2021 and 2023 thanks to
the strong rebound in revenue and the drop in additional expenditure linked to the health crisis.
From 2024, however, the deficit is expected to stagnate at around €
15 billion, pausing the
catch-up in revenue; while additional long-
term expenditure, including the “Ségur de la santé”,
remains unfunded.
Graph no. 5: change over time in deficits from the general social security scheme (and
the FSV) and of the healthcare branch within it
from 2019 (in €
Source: Court of Accounts, based on the 2019 and 2020 accounts of the branches of the general scheme and the
FSV age support fund and the forecasts of the social security finance bill for 2022
Ultimately, the healthcare branch of soci
al security could accumulate more than €
billion in deficits (“social debt”) between 2020 and 2025, with half of that between 2022 and
2025. Admittedly, part of the income from the family, occupational health and even
independent living branches, for which surpluses are expected, could be reallocated to the
healthcare branch. However, the deficits of the old-age branch and the FSV also need to be
Health insurance must not be left in long-
term deficit. While today’s debt financing of
social spending transfers the burden to future generations, its return to equilibrium is an
imperative for intergenerational equity. Although the financial outlook for pensions makes
headlines, the issue of the financial sustainability of health insurance is no less important.
In its publications, the Court has identified many possible sources of savings that would
improve the financial sustainability of health insurance. Depending on the specific case, these
approaches either assign more demanding objectives to the actions undertaken by the Ministry
of Health and the health insurance system, prompt the re-examination of certain
developments, or are new in nature. The approaches put forward by the Court, which do not
claim to be exhaustive, relate to four series of drivers of action: the structuring of care;
remuneration of stakeholders in the health system; avoidable causes of health expenditure
and health insurance; and the contribution of digital technologies to the transformation of the
health system.
A. Health system stakeholders must be better organised in line with the
objectives of accessibility, continuity, quality and safety of care
1 - The structuring of primary care must be improved
In 2020, France had nearly 129,000 doctors practising exclusively on a self-employed
basis or partly as employees of a healthcare structure, including a small majority of general
practitioners, for 67 million inhabitants.
At the same time as the French population and the health care needs associated with
its ageing are growing, the medical time available is decreasing due to the long-term effect of
the numerus clausus applied over the past few decades, retirements and the lack of
establishment of some doctors, who prefer to fill vacancies or act as part-time replacements
for colleagues, often in well-funded geographical areas.
According to the analysis by the Ministry of Health (study published in February 2020),
the share of the French population living in geographical areas that are under-staffed with
general practitioners, while remaining low, is increasing: between 2015 and 2018, figures
suggest that it increased from 3.8% to 5.7%. Local elected officials and their constituents often
have a more negative perception of the extent of these situations.
Furthermore, the lack of availability of doctors in large towns, particularly following the
2003 abolition of the ethical obligation to participate in on-call work, has as its corollary the fact
that approximately one in five patients who make use of the emergency services of health
establishments could, or even should, have been taken care of by a community doctor.
In order to free up medical time, the Ministry of Health encourages assisted work: for
example, orthoptists prepare the way for consultations with ophthalmologists by carrying out
visual assessments. In addition, the health insurance system pays doctors subsidies for hiring
medical assistants. Calls for projects also aim to introduce services for access to care, which
are intended to filter patient access to hospital emergency units.
Beyond that, two more far-reaching developments could make it possible to provide a
more effective structure for first-response care.
Two potentially far-reaching transformations: advanced practices by paramedical
professionals and sub-national professional health communities
The health system reform law of January 2016 provided nurses holding State
qualifications with the possibility of working in advanced practices; i.e. performing work and
using more advanced skills that had hitherto been assigned to doctors. To this end, they must
provide proof of a minimum period of work in their profession and of a two-
year master’s degree
issued by an authorised university.
In application of the “Ma santé 2022” ministerial plan announced in the fall of 2018,
professional sub-national health communities (CPTS) must coordinate the work of volunteer
city professionals on the basis of a given (urban or rural) population. They have six missions:
preventive work; guaranteed access to a medical practitioner; providing appointments with a
general practitioner during the daytime if necessary; access to consultations with medical
specialists within appropriate time frames; providing safe transit between community care and
hospital, in particular in preparation for a hospital admission or for discharge from hospital after
an admission; home support for the frail, the elderly or those suffering from multiple
To date, however, the scope of such change has failed to achieve its full potential.
For example, the “Ma santé 2022” plan set the objective of 1,000 CPTS communities
by 2022. By mid-October 2021, 159 CPTS communities, covering 14.4 million people in
principle, had been formed. Insufficient time has passed to assess the contribution they have
made to fluid continuity of care within the framework of specific territories.
A primary care service, provided by health professionals trained over intermediate
periods between the 3 years of initial training specific to traditional paramedics and the 9 to 12
years of initial training for doctors, is struggling to emerge: unlike in English-speaking countries,
advanced practice nurses will work only within a team coordinated by a doctor, mainly in
hospitals or medico-social establishments, and rarely in the community. In addition, the
Ministry of Health is aiming for 3,000 trained professionals by 2022, i.e. less than 0.5% of the
744,000 nurses practising in 2020 (including 480,000 in health establishments and 131,000
working exclusively in private practice or also as employees).
In addition, the formation of representative offices of professionals into a national union
of health professionals has not succeeded in laying the foundations for an effective multi-
professional dialogue with health insurance, because of a lack of internal arbitration powers.
Inter-professional agreements with the health insurance system are added to agreements that
are negotiated on a profession-by-profession basis, without defining their priorities. The result
is a brake on the development of interprofessional approaches and a layered accumulation of
financial benefits on a per-profession basis.
There is a need to continue to work on the definition of the skills of paramedical
professionals involved in continuing, training, to promote co-ordinated work between health
professionals in order to mitigate the impact of changes over time in medical demography on
access to care, and to improve the efficiency of resources assigned by the health insurance
system to simple acts that do not require the intervention of a doctor.
Beyond that, the acute nature of territorial inequalities in the distribution of community
doctors in relation to actual need calls for the establishment of a selective agreement based
on their geographical density, as is the case for nurses and masseurs/physiotherapists. To be
effective, this mechanism should cover not only established doctors but also locum doctors.
2 - Quality and safety issues require increased rationalization of the structuring of
care in healthcare establishments
As of 2020, France has nearly 3,000 health establishments, all types of activity
combined (including just over 1,300 public establishments, nearly 700 non-profit private
establishments and nearly one thousand for-profit private establishments) . As has been
pointed out, better structuring of primary community care would reduce the demand for
healthcare establishments and the tensions thus generated. Beyond that, there is also a need
for a reorganisation of the supply of care in health establishments.
The density of Fr
ance’s network of health establishments, which is slowly shrinking,
induces additional costs linked to the duplication of administrative services and technical
platforms that are sometimes underused. In addition, establishments are often faced with
serious recruitment difficulties and persistent vacancies, and resort to costly palliative solutions
(temporary staff). Given the growing complexity of a portion of the care techniques
particularly in surgical terms
the geographical fragmentation of the establishments seems
less and less well suited to the issues of quality, safety, relevance and efficiency of care.
In 2016, regional hospital groups (GHTs) were created, in which all public health
establishments are required to participate. Their purpose is to establish regionalised
healthcare channels and provide a graduated structure for care services, in order to ensure
equal access for patients to safe and high-quality care. However, the GHTs come in a diverse
range of sizes, and some do not offer the minimu
m “basket of care” expected. Although the
GHTs must have a shared medical plan and jointly conduct certain activities (pharmacy,
imaging and biology activities) and functions (purchasing, medical information, information
systems), the “individual establishment” philosophy often continues to prevail.
There is a need to revise the scope of the GHTs so that all offer a coherent care
package, to strengthen joint departments and to encourage the establishments to merge into
a single legal entity capable of stimulating the redeployment of inter-site activity. Further
integration of establishments within the GHTs appears particularly essential in order to ensure
efficient use of the budgets that the public authorities have decided to allocate to hospital
1.5 billion between 2021 and 2025 for current investments, €
1 billion between
and 2025 for new projects under the “France
Relance” recovery plan financed by the
European Union, and €
5.5 billion over 10 years financed by the social debt write-off fund).
The 30 university hospital centres are diverse in nature, and vary in their ability to carry
out their missions. Some establishments, including the APHP (Assistance Publique
de Paris), are experiencing recurring deficits. The establishment of a network of ten or so CHU
university hospitals would bring greater critical mass and international visibility to research
activities. With regard to healthcare activities, there is a need to reduce the significant
differences in productivity between CHUs, which are not justified by objective differences in
status, and to strengthen the relations of the CHUs with the establishments within their
territorial jurisdiction, in order to rationalise the establishment of technical platforms.
Considerations of quality and safety of care still occupy an insufficient place in the
operating licences granted to public and private health establishments. The persistent absence
of minimum activity thresholds for most surgical procedures (apart from oncology) should be
ended, thresholds currently in force should be raised and the set thresholds should be
effectively enforced.
The number of hospital beds in medicine, surgery and obstetrics is decreasing, while
the number of outpatient places is increasing. These changes reflect changes in patient care
techniques: between 2011 and 2019, all establishments combined, the number of medical,
surgical and obstetrical stays fell from 11 to 10.6 million, as did their average duration (from
5.7 to 5.5 days), while the number of hospital admissions without overnight stays increased
from 6.4 to 8.4 million.
Graph no. 6: Change over time of the number of beds and places in public and private
health establishments in mainland France between 2013 and 2020 (as %)
Source: Department of Research, Studies, Assessment and Statistics (DREES) of the Ministry of Solidarity and
Health, studies and results, September 2021, No. 1208
Daytime hospital admissions, without overnight stays, are more convenient for patients
and less costly for health insurance. In health establishments, the outpatient method of care is
increasingly common in surgery, at the cost of temporary overfunding of charges, but room for
improvement remains: for 34 specific procedures at international level, the rate of outpatient
surgery averaged 59.4% in 2020, compared to 43.1% in 2010, with a target of 70% in 2022. In
medicine, the outpatient method is still in its infancy due to a lack of sufficient pricing incentives.
The reorganisation projects for the health establishment activities proposed here will
need to enlist the support of their staff if they are to succeed. In addition to the“Ségur de la
santé” pay revaluations, internal changes to health establishments in relation to healthcare
team projects, the organization of activities and working relationships appear desirable.
B. Remuneration of stakeholders in the health system must be reformed
in order to reduce economic rent, improve quality of care and slow
increases in the most dynamic expenditure
Expenditure regulation instruments should be used with increased frequency
and over broader scopes
Expenditure on drugs in community settings (dispensaries and direct hospital sale of
drugs to outpatients) is under control: since the mid-2010s, their net amount has been stable
at around €
22 billion per year after deduction of rebates paid by pharmaceutical companies.
The same is not true for expenditure on medical devices (€
7.5 billion), which is particularly
dynamic (+4 to 5% per year). As is the case with drugs, the Ministry of Health should make
more active use of the prerogatives granted to it under social security financing laws in order
to influence the prices of medical devices and regulate the overall change over time in related
Hospital prescriptions in community settings are growing in importance in all community
healthcare expenditure (22% of prescriptions produced in the community in 2019, compared
to 17% in 2004). Although recently renovated, the effectiveness of the prescription regulation
mechanisms is inconclusive. They should be made more demanding.
Although 60% of patient transport expenditure (€
4.7 billion) relates to trips between
homes and establishments, healthcare establishment budgets currently only fund transport
expenses within and between these establishments. In order to promote a more efficient
approach to patient transport, establishments’ budgets should include all transport expenditure
arising from prescriptions produced there.
Health care charges should enable health insurance to benefit from a greater
share of the productivity gains made by stakeholders in the health system
The aim of payment on a fee-for-service basis for community medical and paramedical
professionals and a per-stay basis for medicine, surgery or obstetrics for healthcare
establishments is to enable remuneration for an identified care activity on the basis of that
activity’s production costs.
However, the charging categories include several thousand distinct items that often rely
on complex definitions. They are not updated frequently enough to accurately reflect progress
in care techniques by including new procedures and appointments, but also by deleting others
which have become obsolete or even detrimental to patients, or less efficient. In addition,
pricing is imperfectly correlated to the burden and complexity of care, and therefore to health
system stakeholders’ actual production costs.
Sometimes, the hierarchy of pricing favours the most expensive modes of coverage for
health insurance, despite their
not being the best suited to the patient’s situation.
Pricing that can promote inadequacies in the care of patients
In the hospital sector, the drop in average charges for admissions between 2011 and
2018 encouraged a race to increase work volumes, facilitated by productivity gains. In some
cases, however, it has been accompanied by reduced relevance and quality of patient care.
Consequently, prior to the health crisis, it had led to unease among some healthcare staff.
Despite being less restrictive for patients whose health conditions permit such modes
of care, self-dialysis and home dialysis are not encouraged from a pricing point of view. In such
a situation, they stagnate or regress: in 2017, 15.8% of patients were on self-dialysis,
compared to 18.5% in 2013; fewer than 8% of patients were on home dialysis (home
hemodialysis or peritoneal dialysis), as in 2013.
The ambulance is the most expensive mode of transport. However, given the role of
ambulances in carriers’ vehicle fleets, particularly in certain
departments, health insurance
remunerates the transportation of patients who hold a prescription for seated transport. In
addition, the regulatory prescription form includes a single section for seated transport, which
encourages the growth of transportation by taxi to the detriment of transport by light medical
vehicle, which is less expensive on average.
In general, the changes made to the pricing categories do not enable health insurance
to benefit sufficiently from the productivity gains made by health system stakeholders.
Productivity gains that health insurance does not take enough advantage of
Innovative drugs with a strong medical benefit are generally very expensive. However,
revisions to the prices of old drugs, for which pharmaceutical companies have long since
written off their research costs, are still too few and far between. To speed up these reviews,
maximum review intervals should be set.
The prices of dialysis sessions (€
3 billion in health insurance expenditure in 2019) are
falling, especially for full-service centres. Nevertheless, the profitability of lucrative private
dialysis systems remains at a high level (with an average operating result of the order of 15%
of turnover), three times higher than the average for healthcare activities of any kind in for-
profit private systems. Health insurance does not make sufficient benefit of productivity gains
in the sector, which are enabled by factors such as reductions in the price of consumables
necessary for renal filtration.
The tendency towards concentration of analysis sites has enabled biological analysis
laboratories to achieve economies of scale, thanks to the pooling of technical platforms and
support functions and the strengthening of their bargaining power with their suppliers (reagents
and raw materials). Health insurance (€
4 billion in expenditure in 2019) does not benefit
sufficiently from this: between 2009 and 2016, the net income of laboratories fell from 9 to 10%
of their turnover; at 16%, their economic profitability is twice the average across all sectors of
the economy.
Cardio-neurovascular diseases illustrate the existence of windfall effects for some
admission pricing, linked to excessive differences between prices and costs, between the
respective prices in the public and private for-profit sectors and between prices specific to the
different severity levels of patient care.
Remuneration paid to health system stakeholders should be based less on fee-
for-service or per admission, and more on lump-sum payments
In 2019, fee-for-service or admission-based payments accounted for 83% of health
insurance funding for public and private non-profit health establishments with medicine,
surgery or obstetrics activities, 98% for for-profit private establishments with the same activity
and 93% for community doctors.
This financing structure encourages an increase in the volume of care and in related
In order to contain the growth of expenditure linked to chronic diseases, it would be
advisable to experiment with an annual individualised per-patient budget, modulated according
to the patient’s health condition and needs. This budget would include all medical and
paramedical care in the community and in health establishments. There would also be tighter
regulation of fee overruns to ensure that this remuneration package is not circumvented.
In addition, health system stakeholders have insufficient incentive to change their
practices to take into account the objectives of public health and control over expenditure set
by the public authorities.
Whereas conventional agreements encourage undifferentiated increases in pricing or
the identification of new actions by marginal differentiation from already recognised actions,
future increases in remuneration for health professionals would be intended to be delivered
within the framework of flat rates to ensure that they received measurable and effective
compensation. Remuneration based on public health objectives could be the preferred means.
Contributions made by the system of remunerating doctors on the basis of public
health objectives (Rosp)
Rosp was created by the Convention médicale Act of 2011. It plays a role in preventing
pathologies (for example by carrying out early examinations) or adverse effects (medicinal
In addition, it plays a direct role in controlling expenditure by encouraging doctors to
increase the share of generics in their drug prescriptions. This share (16% in value and 30%
in volume) remains much lower in France than in Germany or the United Kingdom (35% in
value and more than 80% in volume): the increased use of generics continues to be driven first
and foremost by alterations of prescriptions by pharmacists (who are encouraged to do so by
a specific Rosp), rather than on their prescription by doctors.
In 2020, the Rosp was paid to just over 72,000 doctors for a value of €
280 million. It is
aimed mainly at general practitioners (96% of the total). Cardiologists and gastroenterologists
are the only specialists eligible to receive it. Other healthcare professionals with authorisation
to prescribe do not receive it.
C. Preventable sources of health expenditure and health insurance costs
should be resolutely reduced
There needs to be a change of scale in disease prevention efforts
As has been pointed out, chronic pathologies that are frequently caused or aggravated
by specific actions and lifestyles have a very heavy human and financial cost.
Contrary to popular belief, the primary (reduction in the number of new cases),
secondary (screening of patients) and tertiary (less worsening of the patient’s situation)
prevention of pathologies receives major public financial support, especially from health
insurance, which can be estimated at approximately
15 billion per year.
The fact remains that our health system is predicated predominantly on curative
medicine. The medical profession often still struggles to address the issue of lifestyle habits
unless explicitly requested by patients
and to take a more active role in preventing
pathologies, despite the financial incentives of health insurance (patient flat rate for the
attending physician, remuneration based on public health objectives).
Since 2018, public authorities have embarked on a resolute policy to reduce tobacco
consumption by raising taxes, which has had tangible effects: the number of smokers has
fallen as an absolute number. On the other hand, they have not made any significant effort to
reduce alcohol consumption, which continues to be high compared to most European
countries. One in two inhabitants is overweight and one in six is obese; this is less than the
average for OECD countries, but twice as many as in Italy. However, the supply of products of
good nutritional quality continues to be dependent mainly on self-regulation in the food industry
and mass distribution.
Stronger price signals should be sent. For example, the taxation of alcoholic and sugary
drinks should be increased, and processed food products with a high added sugar content
should be subject to specific taxation. In addition, the reimbursement of part of the curative
care via health insurance could
within certain limits
be contingent upon the responses of
insured parties to the offers of pathology screening tests that they receive. Finally, it would be
advisable to increase the share of remuneration paid to doctors in connection with preventive
action performed.
There should also be more extensive use of regulatory instruments. The ban on
advertising of alcoholic beverages introduced by France’s Loi Évin, which has been impacted
by widespread exemptions, should be reinstated. In addition, maximum salt, sugar and fat
levels in the nutritional composition of foods should be set. Consideration should also be given
to an obligation to display the Nutriscore as part of the system of nutritional claims that must
be reported to the Commission and to the other Member States of the European Union.
Another prevention issue concerns pathologies caused by the health system.
A need for improved prevention within the healthcare system itself: nosocomial
infections and antibiotic resistance
Healthcare-associated infections are believed to be responsible for approximately
4,000 deaths per year. Although the figure decreased between 2001 (6.9%) and 2006 (5%),
the prevalence of infected patients has stagnated at this level since then (compared with less
than 4% in Germany or the Netherlands). There is a need to reshape hygiene teams in health
establishments, to reconsider the suspension of the influenza vaccination requirement for
health professionals and to withdraw the operating licences of health establishments which fail
to correct the failures noted by the High Health Authority within a specified period of time. In
addition, the prevention policy should be extended to community medical and paramedical
Antibiotic resistance was responsible for more than 5,500 deaths in 2015. Despite a
slight decrease, especially among young subjects, the per capita consumption of antibiotics
remains twice as high in France as in Germany, and two and a half times higher than in the
Netherlands. It is important to promote changes in doctors’ prescribing behaviour through
adjustments to their ongoing training and the Rosp, and to require pharmacists to dispense
antibiotics on a per-unit basis.
Some expenses need to be refocused on their end use: the case of daily
Expenditure relating to daily allowances for illness and for occupational accidents or
disease (€
8.7 billion and €
4.9 billion respectively in 2019) is very dynamic (+ 3 to 5% per
year). The increase in the average retirement age is not the only explanatory factor for this
state of affairs: the average number of days off work is increasing among most age groups.
Stakeholders in sick leave compensation expenditure should be made more
accountable: doctors who prescribe sick leave, employees who request sick leave and
employers, whose working conditions may con
tribute to their employees’ demand for sick
France’s national CNAM health insurance fund estimates that there are approximately
7,000 highly prescribing doctors, another 7,000 very highly prescribing doctors and 700 to
1,000 over-prescribing doctors. However, the health insurance system applies coercive
measures (the establishment of targets or prior agreements) only to a small fraction of these
doctors. It needs to supply all doctors with data to enable them to rate their own practices
against those of their colleagues and encourage doctors to consider benchmark durations for
benign pathologies within the framework of e-prescription services for work stoppages that it
supplies to doctors
the use of which is intended to become compulsory during late 2021.
The dynamics of annual lengths of work stoppages also reflect the impact of working
conditions. In fact, these time periods vary greatly by sector of activity: in the health and
medico-social sectors, they are almost twice as long as in construction or in industry. In order
to encourage employers to make more effective changes to jobs, work structures and working
relationships, it would be appropriate, without changing the level of compensation to
employees, to increase the share of compensation for which they are directly responsible, and
to reduce the share from health insurance. This deferral of funding should cover all work
stoppages, not just short-term stoppages.
Finally, in order to prevent the occupational exclusion of employees with a series of
frequent work stoppages, it would be advisable to provide more effective support for the return
to work in the form of early engagement with the employee by the health insurance system, in
conjunction with the employee’s GP, with the employer and the oc
cupational health service
also involved over the duration of the work stoppage.
In pursuit of the same goal, a disability pension (€
7.6 billion in benefits in 2019) could
be offered for a defined period for insured persons closest to employment, giving them access
to enhanced social and professional support. At the end of this period, the medical section of
the health insurance system would assess whether it is appropriate to renew the pension,
suspend it, or recognise a higher level of disability.
Enhanced measures to verify the legitimacy of healthcare refunds would generate
significant health insurance savings
A non-negligible fraction of the health expense reimbursements paid by health
insurance is generated by invoices from professionals and health establishments for care,
goods or services that are fictitious, overpriced or not in accordance with the rules set by pricing
Whether they result from involuntary billing errors or fraud, the wrongful reimbursement
of health costs, essentially by the third-party payment system to professionals and
establishments, has a high cost for health insurance: according to a partial estimate produced
from a sample of invoices, health insurance is believed to have wrongly paid around €
2 billion
in 2020. This is a conservative estimate: it does not include errors made by public and private
not-for-profit health establishments when invoicing for admissions, for which no estimate is
available. It merely reveals the most visible errors in this incomplete area, excluding less easily
detectable items such as fictitious invoices for care, goods or services.
The control measures implemented by the health insurance system do not sufficiently
protect its financial interests.
Consequently, health insurance should introduce or reactivate automated controls in
its information systems, which should serve to prevent a greater number of irregular invoices.
In addition, the health insurance system should reintroduce in-depth checks on billing
in health establishments
which were still suspended in 2021
and increase the frequency of
such checks: prior to the crisis, only in 0.6 to 0.7% of admissions were invoices actually
checked against the information in the patients’ medical files. The health insurance system
should also increase the number of retrospective audits on invoices sent to it by community
professionals: it often continues to pay professionals who bill it for abnormally high, if not
absurd, activity (several hundred thousand euros in annual fees).
This issue of the legitimacy of reimbursements of health costs made by health
insurance is more far-reaching than simply searching for and preventing demonstrable fraud.
It involves an in-depth review of the methods of managing these reimbursements and, in doing
so, a rebalancing of the reciprocal rights and obligations of stakeholders within the health and
health insurance system.
Under certain conditions, digital technologies can improve efficiency
in the health system and health insurance expenditure
Following the failure of a number of projects (the Dossier médical partagé electronic
health record), 2018’s Ma santé 2022 ministerial plan introduced a large
-scale digital health
services initiative: an electronic personal medical file, secure digital messaging between health
professionals in the community and in hospitals, e-prescription services, and new services
accessible by social security beneficiaries via their personal “Ameli” accounts.
Digital technologies offer unprecedented potential to improve the efficiency of the
health system and enable savings within the health insurance system.
Major changes are under way. In 2022, an electronic DMP health record will be created
for all policyholders, unless they object (only 10 million DMPs have currently been opened).
The health crisis has been accompanied by a strong upward trend in remote consultations,
which will not return to their previous low level. Having established work stoppage and patient
transport services, the health insurance system is setting up e-prescription services for drugs
and medical devices
which should enable France to catch up with most of its neighbours
and has plans to do the same for biology and paramedical procedures; healthcare
professionals and institutions will in theory be required to use these services by 2024. The
“France Relance” recovery plan will set aside €
1.4 billion for extending the use of digital
technology in healthcare and €
0.6 billion in the medico-social sector.
However, there are difficulties to be overcome. For example, the Ministry of Health
needs to establish technical standards to ensure the interoperability of all health system
stakeholders’ information systems and, with regard to e
-prescriptions for health products, the
use of generic and non-commercial items. It is also important for software publishers to provide
healthcare system stakeholders with software solutions that comply with these technical
standards. Finally, all stakeholders will need to take ownership of the new digital services:
doctors will be required to produce summary reports to ensure that the DMP health record
stores structured and usable information; healthcare establishments will be required to connect
their information systems to digital health insurance services while maintaining a distance from
Finally, digital healthcare technology must actually deliver net savings for health
insurance. This means that the new expenditure required by the use of new services must be
less than the savings enabled by the use of digital technology. To this end, it will be particularly
important to establish a non-inflationary financing framework
that is not based on fee-for-
service payment
to finance remote monitoring by the health insurance system.
In order to reduce the health insurance deficit, the Court thus calls for action to be taken
on the determining factors and formative mechanisms influencing expenditure on health and
health insurance.
Most of the savings discussed in this policy paper could be achieved within a few years.
By increasing annual savings (essentially on hold since 2020) by 50% compared to the
previous level of between 3 and 4 billion euros, health insurance could be restored to financial
equilibrium before 2030, without increasing the levies associated with it or reducing the scope
or value of its reimbursements.
Conversely, a reduction in the level of social coverage of health financing by health
insurance would lead to spending being transferred to supplementary health insurance and
patients themselves. Supplementary insurance providers would then raise their rates, which
would accentuate their costly and unequal nature, while reducing access to healthcare for
certain patients. Although such a future path is not being recommended by the Court, nor
discussed today in public debate, it could nevertheless come to the fore, sooner or later, in the
absence of more determined and continuous efforts on expenditure.
The Court has carried out a great deal of work in recent years on which it has relied, in
particular the following publications:
Public health prevention policies
, communication to the Social Affairs Committee of
the National Assembly, november 2021
The financial trajectory of social security from 2020: the challenge of the
consequences of the health crisis,
annual report on the application of social security
financing laws (RALFSS), october 2021
Health insurance expenditure: a need for revised regulations,
RALFSS, october 2021.
Telehealth: tools to be used to coordinate care,
RALFSS, october 2021
Medical biology expenditure: efficiency efforts still insufficient,
RALFSS, october 2021
Paperless medical prescriptions: a factor in the efficiency of the health system,
ambitious projects requiring completion,
RALFSS, october 2021
Supplementary health insurance: a highly protective but inefficient system,
communication to the Social Affairs Committee of the National Assembly, june 2021
Health insurance expenditure between 2010 and 2019: progress in overall control of
expenditure, reforms to be stepped up,
RALFSS, october 2020
Sub-national hospital groups: a mixed picture requiring the continuation of reform
RALFSS, october 2020
Regulation of expenditure on medical devices: control measures to be accentuated,
RALFSS, october 2020
The fight against social benefits fraud: slow progress, a change of scale required,
communication to the Senate Social Affairs Committee, september 2020
End-stage chronic renal failure: a reform in care needed to serve patient needs,
annual public report, february 2020
Obesity prevention and management,
communication to the Social Affairs Committee
of the Assemblée Nationale, November 2019
Daily allowances: rising expenses for health risk, a need to control work stoppages,
RALFSS, October 2019
Disability pensions: modernisation required to provide enhanced support for insured
RALFSS, October 2019
Scheduled transport in the health and medico-social sectors: more recognition of
required, regulations need rebuilding,
RALFSS, October 2019
Policy for prevention of healthcare-associated infections: a new obstacle to be
annual public report, February 2019
Hospital emergencies: services still overstretched,
annual public report, February
The role of university hospitals, observations to the Prime Minister, December 2018
and The role of university hospitals in the provision of healthcare
, communication to
the Senate Social Affairs Committee, November 2018
Ten years of change in healthcare systems and coverage of healthcare expenditure
in Europe: profound changes, lessons for healthcare system reforms in France,
RALFSS, October 2018
The shift to outpatient care in the health system: new transformations required, both
in the community and in hospital,
RALFSS, October 2018
The fight against cardiovascular diseases: the need for prioritised prevention and
quality of care
, RALFSS, October 2018
Eye care: reform in management needed,
RALFSS, October 2018
The future of health insurance, Ensuring efficiency in expenditure, empowering
public thematic report
Private speciality medicine: containing the dynamics of expenditure, improving access
to care,
RALFSS, September 2017
Surgical activities: restructuring the care package to provide better quality of care,
RALFSS, September 2017
Drug pricing: significant results, major issues of efficiency and sustainability remain, a
framework for action that urgently needs rebalancing,
RALFSS, September 2017
Policies to combat harmful alcohol consumption,
public thematic report
This report is available
on the Court of Accounts website: