SOCIAL SECURITY

Report on the implementation of the Social Security

Finance Act

Executive Summary

May 2023

2

Executive Summary

In its latest annual public report

1

, the Court of Accounts noted that France’s public

finances will still be among the worst in the eurozone in 2023. It pointed to the high risks of

sustaining French public debt in the medium term. The Court therefore considers that it is no

longer possible to postpone the action needed to sort out the public finances.

Following the adoption of pension reforms and the review of unemployment insurance

rules, the government announced an annual review of expenditure in order to identify ways in

which public policies can be more effective and more economical. The Court will be issuing

further recommendations in specific publications in the coming weeks.

The report on the implementation of the 2023 Social Security Finance Act (LFSS) will

now focus on:

- analysing the financial position of the social security system at the end of 2022 in order to

inform

Parliament’s vote on the law approving the social security accounts, the draft of

which is presented to Parliament for the first time in May (Part I);

- taking stock of the implementation of reforms or measures decided on in recent years by

the Social Security Finance Acts and assessing, in particular, their contribution to the

control and quality of social security expenditure (Part II);

- illustrating, through four examples, the need to initiate the changes required to achieve

greater efficiency in public spending within the social security sector (Part III).

1

Court of Accounts,

la situation d’ensemble des finances publiques

(à fin février 2023), rapport public annuel 2023

[the overall picture of public finances (as at end of February 2023), annual public report 2023].

3

I -

The social security system’s financial situation needs

to be straightened out

After analysing the situation of the social security accounts in 2022, the forecasts for

2023 and their trajectory for the coming years (Chapter I), the report takes an in-depth look at

changes in health insurance expenditure and puts forward proposals to make their

management more effective (Chapter II). Finally, it assesses the quality of the new information

provided to Parliament on the financial position of healthcare institutions and recommends the

improvements needed to increase its relevance and completeness (Chapter III).

1 - The financial situation of the social security system: a temporary

improvement with a deterioration forecast

The deficit of the mandatory basic social security schemes (ROBSS) and the old-age

solidarity fund (FSV) at 31 December 2022 was €

19.6bn, i.e. 0.7 % of GDP. Its improvement

of €

9.7bn compared with the adjusted 2021 result (see box) remains modest given the scale

of the economic recovery (GDP growth of 2.6 %) and the rise in inflation (+5.3 % excluding

tobacco), which contributed to the increase in revenue (rise in the wage bill of 8.7 %).

Change in the aggregate deficit of the mandatory basic social security scheme and

special incapacity fund (FSI) (2009-

2022, in €bn)

Note: the LFSS for 2022 adopted the accounts with a deficit in 2020 of €39.7bn. Taking into

account the adjustment to the 2021 deficit approved by Parliament in the LFSS for 2023, less

€

5b

n of income relating to 2020, the corresponding balance for 2020 is €

34.7bn.

Source: Court of Accounts, based on the PLACSS for 2022 and the balance schedules approved

by the LFSS for previous years

Very close to breaking even in 2018 and 2019, the social security balances were

seriously eroded by the health crisis in 2020 and 2021. From 2021 onwards, the rebound in

growth and the recovery in employment then restored revenue and promoted a gradual

recovery. At the same time, however, spending has risen sharply as a result of the extension

of the health crisis until 2022 and the rollout since 2020 of the ‘

’, a multi

-year

programme of pay rises and structural investment in hospitals and medico-social institutions.

4

In 2022, the health insurance branch had a defic

it of €

21bn, higher than that of the social

security system as a whole, and €

1.9bn worse than the initial forecast.

The deficit of the old-

age pension branch is growing, amounting to €

3.8bn in 2022. This

deficit is attributable to the general scheme (€

2.9bn) and the hospital and local civil service

pension fund (CNRACL, €

1.8bn), with the other schemes either in surplus or in balance. For

the state civil service scheme and several special schemes, this balance was achieved through

the payment of contrib

utions or subsidies totalling €

51.3bn in 2022.

The other branches (accidents at work and occupational illnesses, family, autonomy) are

in surplus. Their results are in line with or better than the initial forecast.

The 2022 social security result is therefore close to the forecast made in the initial Budget

Act (an improvement of €

1.8bn). However, this masks a sharp rise in revenue offset by an

equally sharp rise in expenditure, despite which the Government has not tabled a

supplementary Budget.

Revenue (

€

572bn) thus exceeded the initial forecast by €

22.8bn. On a like-for-like

basis, it was €

64.2bn higher than in 2019, before the health crisis. This growth is explained by

the positive change in the private sector wage bill, driven by the good level of employment

(+2.7 %) and by the increase in the average wage per capita (+5.8 %), supported by the

increases decided on against the backdrop of inflation. The 3.5 % increase in the civil service

index point on 1 July 2022 generated additional charges and con

tributions of €

1.1bn for the

social security system in 2022. Net earmarked VAT (€

46.4bn) remained a dynamic resource

(+4.7 %).

Expenditure (€

591.6bn) exceeded forecasts by €

21bn. There were two main reasons

for this sharp increase: the effects of the health crisis, which were greater than expected, and

the 4% increase in social security benefits adopted on 1 July 2022 in anticipation of the 2023

annual increase to prevent the effects of inflation on the purchasing power of beneficiaries.

For health insu

rance, the approved national expenditure target (ONDAM) (€

236.8bn)

was exceeded by €

10.4bn, of which €

6.8bn was due to crisis-related expenditure. The

increase in spending by other branches was mainly due to the effect of increases in social

security benefits.

In 2023, the balances of the basic social security schemes should continue to

improve, thanks to economic factors: continued revenue growth and a decline in crisis-

related expenditure.

The Social Security supplementary Budget for 2023 forecasts a d

eficit of €

8.2bn, a

marked improvement of €

11.4bn. Expected growth in revenue from charges, contributions and

earmarked taxes (+4 %) will continue to be driven by inflation and the improved employment

situation. The increase in expenditure is expected to be lower (+1.7 %). After the early

increases in pensions and social security benefits in July 2022, those in 2023 will be more

moderate.

The biggest turnaround will be in the healthcare branch, where the deficit will be reduced

from €

21bn to €

7.1bn. Primarily, it will result from the reduction in crisis-related expenditure

from €10.7bn to €1bn. However, it is also based on an assumption of a 3.6

% increase in the

ONDAM excluding the crisis, which is lower than inflation and which assumes efforts to control

spending that have yet to be confirmed.

The pension reform has only marginally altered the 2023 deficit forecast. The increase

in pension minimums for full pensions is due to apply from 1 September 2023, at an estimated

additional cost of €

0.4bn in 2023. The impact of extending the retirement age and increasing

the length of insurance required for new pensioners (€

0.2bn in savings expected in 2023) is

more gradual and, for the first year of application, is expected to be offset by the other support

measures.

5

From 2024 onwards, the deficit is set to deteriorate despite the expected effects of

the pension reform

The improvement in the financial position forecast in 2023 is only expected to be

temporary. From 2024, the deficit is set to worsen again, driven by the deterioration in the

balances of the old-age branch, which the pension reform is unlikely to restore quickly. The

deficit should then stabilise above €

13bn in 2025 and 2026.

2021-

2026 financial trajectory for branch and FSV balances (in €bn)

Source: Annex to the Social Security supplementary Budget 2023, adjusted for 2021 in

accordance with Article 1 of the LFSS 2023 and for 2022 in accordance with the final accounts

This deterioration will be the result of the economic situation on the one hand and a

structural deficit in the old-age branch on the other, while the increase forecast in healthcare

expenditure will be tightly controlled.

In fact, in 2024, revenue is expected to slow as inflation falls and the labour market

becomes less buoyant, ac

cording to the Government’s wage bill assumptions. At the same

time, pensions and benefits should reflect inflation in 2023, having been increased by the

stability programme.

Effect of inflation on the social security balance

If inflation rises or falls, the effects are quickly felt on social security revenue, 85 % of which is

based on salaries and consumption. The effects on expenditure are slower, with a one-year lag for

index-linked expenditure. As a result, unless benefits are increased in advance, like in 2022, social

security deficits will fall when inflation accelerates and rise when it slows down. This effect contributes

to the improvement in the 2023 balance and is expected to contribute to its deterioration in 2024 and

2025.

The assumption concerning the change in the ONDAM, excluding the health crisis,

seems particularly ambitious. Its average annual increase over the period 2023-2026 is

expected to be 2.9 %, barely more than inflation (2.8 %). In the past, it has never been possible

to achieve such moderation over several years. Implementing the planned trajectory would

require a series of reforms aimed at improving the efficiency and quality of care. The Court

noted the most significant of the measures it recommended in a 2021 structural report

2

which

it illustrates in this report, in order to make considerable savings without compromising the

6

quality of care, such as the medical control of healthcare expenditure or the efficiency of

medical imaging.

The pension reform adopted on 14 April 2023 has economic objectives that go beyond

simply restoring the social security accounts. As far as the basic social security schemes are

concerned, the reform will only have a gradual positive financial impact, as the support measures

will take effect more quickly than the age-related measures. This will thus result in additional

costs until the end of 2024. The net gain will be limited to €1bn in 2025 and €

2bn in 2026.

By 2030, under the favourable assumptions of productivity increasing by 1 % per year

and an unemployment rate falling to 4.5 % (7.2 % at the end of 2022), the net impact on the

balances of the old-age branch of the mandatory basic schemes and the FSV would be

€

7.1bn. By this date, the impact of raising the retirement age to 64 and increasing the required

insurance period to 43 years would reach €11.5bn and would be reduced by €

4.4bn by the

support measures

3

.

Impact of the pension reform on the balances of the old-age branch and the FSV (all

ROBSS, in €bn)

Source: Impact study on the reform accompanying the PLFSS, CNAV [old-age insurance fund],

Prisme 2022 model

Taking into account the effects of the reform and regulatory measures, the deficit of the

old-age branch and the old-age solidarity fund (FSV) is expected to reach a maximum of

€

8.8bn in

2025, despite the effects of the pension reform, before falling to €

5.7bn in 2030. In

addition, the effects of the measures adopted by amendment during discussion of the bill in

Parliament have not yet been incorporated into this forecast.

3

Early retirement for individuals with disabilities, long careers, prevention of professional burn-out, increase in

pension minimums, retirement transition measures, increase in the threshold for entitlement to the support

allowance for the elderly (ASPA), creation of an old-age insurance scheme for carers.

7

The change forecast in the balances of the basic old-

age pension schemes and the FSV (€bn)

Source: Impact study on the reform accompanying the PLFRSS, CNAV [old-age insurance fund],

Prisme 2022 model

An increasingly worrying situation for the CNRACL

The CNRACL manages a special scheme that covers the retirement and disability risks of

hospital and local civil service employees. Given that the deficit has become structural and is set to

worsen (€

6.6bn in 2030), the 2023 LFSS authorised the CNRACL to borrow up to a maximum of

€

7.5bn to ensure the sustainability of benefit payments in 2023. This solution is becoming

increasingly expensive as interest rates rise rapidly.

As the financing of social security deficits by the CADES (

Caisse d’amortissement de la

dette sociale

[social security debt repayment fund]) will no longer be organised after 2023, the

adoption of new measures should be accompanied by a credible trajectory to return to a balance.

The existence of the CADES was extended from 2024 to 2033 by the Act of 7 August

92bn in respect of deficits in 2020 and

8.8bn left to cover the 2023

deficit of the general scheme. New solutions will therefore have to be found for the deficits of

the general scheme from 2024 onwards, as well as for absorbing the accumulated deficits of

the CNRACL since 2020.

Any decision to further extend the lifetime of the CADES beyond 2033 must be

accompanied by a credible and sustainable path in order to return to a balance. To achieve

this, a multi-year programme of reforms must be prepared together with a path for restoring

the accounts.

Annex: opinion on the consistency of the balance schedules and of the social security

asset schedule for 2022

For the first time, the bill for approving the social security accounts (PLACSS) submits

schedules to Parliament for approval that relate to the last closed accounting year: these include

balance schedules, which are summary income statements for the social security schemes and old-

age solidarity fund (FSV), and an asset schedule, which is the overall balance sheet of the schemes,

the FSV, the social security debt repayment fund and the pension reserve fund.

The Court ensures that the information contained in these schedules is consistent with the

accounts of the aforementioned entities, that reciprocal transactions between these entities are

correctly removed and that the information provided to Parliament is of high quality.

8

Subject to certain observations, relating in particular to the opinions it has issued on the

accounts of the URSSAF network and the benefit branches of the social security’s general scheme,

in particular with regard to the family branch, which is the subject of an adverse opinion, the Court

considers that, through its balance and asset schedules, the PLACSS for 2022 provides a coherent

representation of the revenue, expenditure and balance of the social security scheme, as well as of

the assets and liabilities of the entities included in the respective fields in these schedules.

In view of the deadlines imposed by the reform of the accounts approval procedure, the date

for closing the schemes’ accounts, producing the schedules and the date on which the Social Security

Accounts Committee delivers its opinion should be brought forward. During this first year of

implementing the reform, the deadlines for the Court to deliver its audit opinions were insufficient.

The Court therefore makes 4 recommendations

aimed in particular at restoring the level of

information that existed prior to the introduction of the law approving the accounts, bringing forward the

timetable for producing the accounts as a result of the introduction of this law and strengthening the

traceability and explanations of the restatements made for the production of the balance schedules,

which include contractions of income and charges that do not comply with the normative framework.

2 - Changes in health insurance expenditure in 2022

Expenditure under the national healthcare expenditure target (ONDAM) has risen sharply

from €

200.4bn in 2019 to €

247.2bn in 2022, i.e. an increase of 5.6 % per year excluding

expenditure related to the Covid-19 pandemic. The increase was 2.3% per year over the period

2017-2019. After t

hree years of sharp increases linked to the ‘

Ségur de la santé

’ and measures to

take account of the inflationary impact in 2022, it is now time to look for efficiency savings in the

healthcare system to ensure compliance with a planned trajectory that is much more stringent.

CHANGE IN THE

ONDAM for the current scope* (€bn)

In 2022, the initial LFSS target was exceeded by €

10.4bn (4.4 %): Covid expenditure was

€6.8bn higher than the initial provision of €4.9bn; measures to compensate for inflation cost

€

2.7bn, including €

1.5bn in salary increases

and €0.8bn in additional amounts to healthcare and

medico-social institutions in order to cope with rising costs in energy, catering and medical

products. €

0.7bn has been spent on emergency measures to increase overtime, and night and

weekend on-call time for public sector hospital employees. Lastly, the high-level of activity led to

unplanned expenditure of €1.5bn, particularly on healthcare products and daily sickness

9

allowances. Most of this expenditure was offset (-

€

1.3bn) by lower expenditure finally recorded in

2021.

Despite the scale of the overruns in 2022, and despite regulatory measures, expenditure

under the ONDAM was not the subject of a Social Security supplementary budget during the

year. These overruns were ratified by a modification to the ONDAM in the supplementary part

for 2022 of the LFSS for 2023.

Compared with 2021, ONDAM expenditure excluding Covid rose by 6.3

%, i.e. €

14bn.

This approach focuses in particular on:

- healthcare institutions and medico-social institutions and services, due to measures to

increase salaries under the

Ségur de la santé

(€2.4bn) and the increase in the index point

for civil servants (€

1.5bn);

-

healthcare products (€

1.4bn);

-

daily allowances (€

1.1bn);

-

and medical and dental fees (€

1.1bn).

2022 IMPLEMENTATION OF THE ONDAM excluding Covid by sub-target compared

with the LFSS and 2021 implementation (€bn)

Source: Court of Accounts, based on information from the social security department

Uncertainties over the implementation of the ONDAM in 2023

The amount of the 2023 ONDAM has been increased (+€

0.7bn) in the supplementary

LFSS of 14 April 2023 to €

244.8bn, of which €1bn is still linke

d to the health crisis. The target

excluding Covid is 3.8 % higher than in 2022.

This change includes the full-year extension of the index point increase to the middle of

2022 (€

1.4bn), the final stage of the

Ségur de la santé

increases (€

0.6bn) and the full-year

extension of the increase in night and weekend on-

call hours (€

0.6bn). Further expenditure

(€

2.1bn) has been earmarked in preparation for negotiations on contractual increases with

10

doctors, masseurs-physiotherapists and health care transporters

(€

0.7bn), as well as for the

needs of medico-

social institutions and services (€

0.6bn) and healthcare institutions (€

0.5bn).

There are uncertainties as to whether this target will be met in 2023, particularly as

regards spending on healthcare products.

Estimated savings are limited to €

1.7bn.

More effective reforms are essential to ensure compliance with the

ONDAM

The increase in the ONDAM excluding Covid in 2023 remains 0.5 points below the

expected inflation rate (+4.3 % excluding tobacco). Such a change represents a major

constraint, even if inflation does not fully affect the ONDAM expenditure. This constraint will

continue in 2024 (an increase less than inflation by 0.2 points).

In order to achieve this trajectory, it is necessary to seek efficiency savings in the

healthcare system. The Court notes the many avenues for reform that it has identified, notably

concerning the reduction of economic rents, better organisation of the players in the healthcare

system based on the objectives of accessibility, continuity, quality and safety of care, and better

control of the highest expenditure.

Recommendations

(Ministries of Health,

Social Security and Public

Accounts)

5.

Reintroduce the 0.5 % alert threshold in the event of overrun of the ONDAM, without

distinguishing between Covid and non-Covid expenditure.

6.

Set aside provisions for the healthcare and medico-social institutions for unforeseen

expenditure, in particular additional costs linked to inflation.

7.

From a multi-year perspective, pursue more vigorously the reforms aimed at improving the

efficiency of ONDAM expenditure, in particular by remedying overruns through regulatory

measures covering all sectors.

3 - Informing Parliament

on the financial position of hospitals: progress needed

The health insurance pays c

lose to €

100bn a year to healthcare institutions, i.e. around

40 % of the annual healthcare expenditure target (ONDAM) voted by Parliament. Regarding

the issues of healthcare institutions operating effectively, it is important for Parliament to have

a clear and complete picture of the change in their financial position when it votes on the LFSS.

An annex to the Social Security Finance Bill (PLFSS) designed to improve

information for Parliament

The Organic Law of 14 March 2022 on the LFSS created a new annex, attached to the

annual PLFSS (‘Annex 6’), the purpose of which is to present the financial position of

healthcare and medico-social institutions.

Previously, an annual report presented the actions taken to finance healthcare

institutions, including a retrospective assessment and a description of planned developments.

This document only devoted a limited amount of space to analysing the financial position and,

moreover, only covered public hospitals. No information was provided on for-profit clinics and

private non-profit healthcare institutions (ESPIC).

11

The Court has endeavoured to assess the quality of the information provided to

Parliament in this new annex, produced for the first time in September 2022 in support of the

Social Security Finance Bill for 2023.

Information that is still insufficient

Out of a 61-page report, the annex devotes just six pages to the financial position of

healthcare institutions, including one page on for-profit clinics and ESPIC, with very limited data

provided. The informati

on is too succinct to understand how the institutions’ results are formed

or the link between the investments decided on and the change in the outstanding financial debt.

Production of information on the accounts needs to be speeded up

The annex to the 2023 PLFSS, published in October 2022, analyses the 2020 accounts.

The 2021 results are presented for public hospitals only, and with considerable methodological

caution, as being

"in the process of consolidation"

and

"provisional"

. This is all the more

perplexing given that the results of the health insurance accounts for 2021 were included in

the 2023 PLFSS that the annex accompanied.

The timetable for producing the accounts of healthcare institutions, which currently runs

until 30 June of the following year, should be brought into line with that of the branches of the

general social security scheme, so that they can be completed before the law approving the

social security accounts for the year is tabled. To achieve this, the Minister for Health should,

as he did before the 2017 financial year, take decisions to unfreeze and delegate the final

budget allocations early enough to enable the regional health agencies (ARS) to pay them to

institutions before the end of the year, rather than in mid-March. If necessary, the amounts

paid may be adjusted at the beginning of the following year, based on actual activity.

12

Comparative deadlines for drawing up the accounts of public hospitals and the

healthcare branch of the social security general scheme (‘health insurance’)

Source: Court of Accounts

Note for the reader: the dates indicated are deadlines

Additional data and analyses to be provided

The annex should provide an analysis of the financial results, ensuring that the income

statement and balance sheet indicators are consistent across the different categories of

institution. In the context of the investment programme launched as part of the ‘

Ségur de la

santé

’ initiative, particular attention should be paid to analysing the level of institutions’ debt,

both retrospectively and prospectively.

Recommendations

8.

In annex 6 to the PLFSS for 2024 and subsequent years, produce for public hospitals,

private non-profit healthcare institutions and for-profit clinics:

-

an analysis of the year’s activity and its impact on reve

nue;

-

a description of all types of funding received by healthcare institutions, the conditions

for placing it in reserve and returning it, and the conditions for granting additional

cash to certain healthcare institutions in difficulty;

-

a retrospective and prospective analysis of investment and debt trajectories, in

particular for over-indebted institutions (Ministry of Health and Prevention).

13

9.

With a view to preparing the annex to the 2024 and subsequent PLFSS, provide a level of

analysis of the financial position of private non-profit healthcare institutions equivalent to

that relating to public hospitals and for-profit clinics, and calculate identical financial

indicators for the three categories of institutions (ATIH [Technical Agency for Information

on Hospital Admissions] and Ministry of Health and Prevention).

10.

Before 31 December, allocate to healthcare institutions all of the budget allocations due

for year n; if the healthcare institutions’ expenditure target is exceeded, offset the

overpayment by adjusting the amount of budget allocations for year n+1 accordingly

(Ministry of Health and Prevention).

11.

Bring forward the deadline for closing public hospitals’ accounts to bring it closer to the

deadline for health insurance (15 March) and set the deadline for the approval of hospital

accounts by their supervisory boards before the deadline for tabling the bill for approving

the social security accounts (before 1 June) (Ministry of the Economy, Finance and

Industrial and Digital Sovereignty, Ministry of Health and Prevention).

14

II - Reforms to be continued

The four chapters of this second part of the report evaluate the implementation of

measures recently decided on as part of the Social Security Finance Acts.

The report prepared illustrates the need to continue reform efforts, whether in relation to

experiments involving rules departing from the organisation and pricing of care (Chapter IV),

the organisation of emergency medical assistance and unscheduled primary care (Chapter V),

compensation for maternity and paternity leave (Chapter VI) or the prevention of benefit fraud

(Chapter VII).

1 - Experimenting to reform the organisation and pricing of care: an initial

assessment of the method promoted by Article 51 of the 2018 LFSS

The limits of the rules on the organisation and funding of healthcare

The organisation of the healthcare system remains compartmentalised and dispersed,

which does not facilitate coordinated and efficient intervention by health professionals for the

benefit of patients, particularly the growing number of patients suffering from chronic diseases.

A general framework for experimentation

Between 2007 and 2017, 23 experiments encouraged initiatives by professionals in the

field. Few of them became widespread. Some were not implemented or have only been

partially implemented. Others were not pursued. Presented as a break with the past, Article 51

of the 2018 Social Security Finance Act introduced a legal framework for departing on an

experimental basis from general organisational or pricing rules, which was intended to facilitate

the use of experiments and their rollout.

Experimenting with different remuneration rules

The purpose of the ‘Article 51’ exemption framework is to encourage health professionals

to adopt a cross-disciplinary approach to healthcare issues without being blocked by the usual

funding rules.

Almost all of the experiments include innovations in terms of funding, by introducing

shared care between primary care and hospitals or new ways of paying for primary care

(particularly concerning the joint intervention of several independent professionals).

By the end of 2022, more than 120 projects had been selected under ‘Article 51’ from

1,073 applications submitted. Total expenditure forecast (up to 2026) for projects currently

authorised amo

unts to €511m. From 2018 to 2022, cumulative actual expenditure amounted

to €

180m.

Too many experiments, an evaluation and sorting process to be reconsidered, and

a rollout strategy to be organised

In order not to rule out

a priori

initiatives in the field, the public authorities decided not to

set priority themes or a maximum number of projects to be authorised, beyond a few major

national

guidelines

(mental

health,

structuring

primary

care,

chronic

diseases,

decompartmentalization

of

care,

elderly

people

and

those

with

disabilities,

and

appropriateness and quality of care). Projects are reviewed as they are submitted, without any

overall vision or comparison between them.

The authorised experiments vary in terms of size, timeframe, area in which they are

rolled out, resources mobilised, purpose, organisation and funding; some appear to compete

with each other or are redundant. For example, 16 experiments are focusing on the elderly, 11

on obesity and 13 on mental health.

15

The large number of experiments being carried out simultaneously makes evaluation a

complex exercise. The systematic review and sorting of projects has not yet been undertaken,

and the strategy for preparing the rollout of those that appear relevant, while observing the

need to control health insurance expenditure, has yet to be defined.

A rollout process to be organised

The rollout work should be carried out under the authority of an organisation coordinating the

action of the Ministry of Health and the national health insurance fund (CNAM). The work to be

undertaken includes, in particular, information systems, changes in skills and professions, training

and coordination. It should be started well before the end of the experiments, which would shorten

the preparation phase for their entry into ordinary law.

Guidelines must be provided to make the legal and technical changes needed for their

rollout.

Recommendations

(Ministry of Health and Prevention)

12.

Limit the inflow of new projects, by ensuring that they correspond to the priority guidelines.

13.

Perform an overall analysis of the evaluation of experiments in the same field and of the

resulting impact on the healthcare system and health insurance expenditure before

deciding on whether or not they should be rolled out.

14.

Provide for the early rollout of the most promising experiments and discontinue those that

fail to meet expectations before completion.

15.

As soon as the experiments have been implemented, identify the practical conditions for

their rollout, particularly in terms of the skills expected of health professionals or the

development of information systems for patient care and billing treatment.

16.

Organise the management of experiment rollout projects within a coordinated framework

between government departments and health insurance services.

2 - SAMU and SMUR [emergency medical services]: ongoing developments to

be continued

Increased use of the SAMU for non-life-threatening care

In the seven years since 2014, the number of calls received by the emergency medical

services (SAMU) rose by 22 %, due in particular to the growth in requests for unscheduled

primary care and the need for transport to hospitals for urgent but non-life-threatening care.

16

Breakdown of calls to the SAMU

Sources: Court of Accounts, based on data from SAE, CNAM and statistics from the Ministry

of the Interior, 2021

Changes underway

A reform of emergency medical transport was introduced in 2022, which includes an

extension of on-call times and better remuneration for private paramedics, at an annual cost

of at least €107m, in o

rder to guarantee medical transport for patients to health institutions.

Access to care services (SAS), which bring together the SAMU and independent

coordinating physicians, were created in 2021 to avoid unnecessary calls to hospital

emergency services for patients who could be treated in primary care. The conditions

governing SAS have yet to be specified, and regulations implementing the law are still awaited.

The successful rollout of SAS will depend on the growing importance of the regional

organisation of primary care, through the local professional health communities (CPTS).

Other changes to consider

SAMU and SMUR services operate at departmental level. Given their varying levels of

activity, the merging of certain medical services provided over the phone or via other

telecommunications devices could be envisaged. The use of nurses, where possible, could

avoid unnecessary use of physicians’ time.

The safety and quality of the requests handled by the SAMU remain a major issue: the

role of medical coordination assistants, which is not overly attractive, suffers from a lack of

trained professionals; service quality indicators have stagnated since 2016, or even declined

slightly, despite the commitment to a national ‘SAMU Quality’ plan at the end of 2018.

17

Following the failure of the national SI-SAMU project, modernising the digital tools

available to the SAMU through the implementation of a re-scaled project is a priority.

Finally, a medical description of SAS and SAMU activity is needed to define the best

solutions for patient care in a given area.

A sharp increase in funding, the impact of which needs to be assessed

The cost of the SAMU-

SMUR is estimated at €

1.2bn a year. The SAMU has benefited

from essential remedial action, with a sharp increase in the funding allocated in 2020 and 2021

(+ €

81m). The SMUR’s funding (€837m in 2020) has not been determined since 202

1 but has

been combined with that of the emergency services since a reform in the same year.

Excluding the SMUR, the projected total cost of the systems contributing to the operation

of the SAMU and SAS increased by 46 % in 2022 compared with 2016 and coul

d reach €

965m

in 2023 (i.e. +62 % compared with 2016).

The regional health agencies (ARS) must put themselves in a better position to measure

the impact of all this funding on the population’s access to appropriate care.

Recommendations

(Ministry of Health and Prevention)

17.

Adapt the regional network of medical coordination platforms (SAMU) to bring their level

of activity into line with the resources to be mobilised.

18.

Adjust the types of emergency medical intervention more according to local needs, in order

to make good use of medical resources (SMUR, inter-hospital nursing transport,

paramedical emergency medicine team).

19.

Effectively manage the rollout of access to care services, in order to assess their impact

on the relevance of responses to requests for unscheduled primary care.

20.

Reinforce the monitoring of the national ‘SAMU Quality’ plan and extend the scope of the

accreditation of the status of the professional practice of physicians and medical teams to

include medical coordination activities.

21.

Meet the new target for the rollout of modernised medical coordination information systems

by 2024 (17 SAMUs equipped).

22.

Organise the collection of medical descriptions detailing the activity of medical coordination

and access to care services in order to establish benchmarks for care within an area.

3 - Expenditure on maternity and paternity leave: entitlement extended, and

management improvements needed

Sluggish spending against a backdrop of falling birth rates

The social security funds paid out almost €3.3bn in benefi

ts for maternity and paternity

leave in 2021, including €328m in daily paternity allowances. These amounts increased by 9%

between 2014 and 2021 (+18.8 % for paternity leave alone), while at the same time the birth

rate fell by 10 %.

This increase is due to the rise in the salary base used to calculate daily allowances

(+2 % per year over the period) and the increase in the length of leave (+3 days).

Increasingly similar entitlement, but some residual disparities

The conditions for entitlement and the methods for calculating benefits for self-employed

workers and farmers have been brought closer to the rules in force for employees. However,

there are still differences in the duration of adoption leave and pre-natal leave that should be

eliminated.

18

Differences in the way mothers use their entitlement to maternity leave

Employed mothers take leave in almost all cases. The situation is different for self-

employed women and farmers: in 2021, only six out of ten took maternity leave. The average

length of this leave also varies from one profession to another.

Average length of maternity leave taken

In days

2014

2021

Change

Female employees under

the general scheme

105

108 or 15.4 weeks

3%

Employed

female

farm

workers

125

121 or 17.3 weeks

-3%

Female farm operators

91

91 or 13 weeks

0%

Self-employed females

73

98 or 14 weeks

34%

Source: Court of Accounts

Longer paternity leave entitlement but varying degrees of take-up

Paternity leave was introduced by the Social Security Finance Acts for 2002. At the time,

lea

ve was for eleven days, in addition to the three days’ paternity leave paid by the employer.

Since 2021, its statutory duration has been extended to 25 days for a single birth, regardless of

the father’s affiliation scheme (employee under the general schem

e, self-employed or farmer).

In 2021, fathers using their leave entitlement took an average of 22 days off work (out of

a possible 25 days). However, according to a study

4

covering the period from 2010 to 2017,

while 74 % of fathers have, on average, used their entitlement to paternity leave, only 33 % of

self-employed fathers have done so. In addition, fathers on permanent contracts make more

use of their entitlement to paternity leave (87%) than those on fixed-term contracts (65 %).

Clarification of funding channels

Since their creation, maternity and adoption leave have been funded by the healthcare

branch, while paternity leave has been funded by the family branch. There is no clear

justification for this disparity. The 2023 LFSS provides for a transfer

of around €

2bn from the

family branch to the healthcare branch to cover post-natal leave. The transfer of expenditure

to the family branch should be completed, while ensuring its financial balance.

Long payment times and risk of fraud

In 2021, payment times were 34.5 days for allowances paid to mothers and 42.6 days for

those paid to employers to reimburse the advance made by these employers to employees

(subrogation). Without waiting for the generalisation of the subrogation, the provision to the social

security funds of the salary statements needed to calculate the allowances should be based on

the employer’s online declaration of employee information [DSN

-

déclaration sociale nominative

].

Major risk areas

In the event of an early return to work not reported by the employer, payment of allowances is

suspended on the presumed date of birth and continued payment is subject to the CPAM receiving

-employed workers, who provide a statement

of truth that they have stopped working, a flexibility that is a source of proven fraud.

19

In addition, the funds must, on their own initiative, verify on a case-by-case basis that daily

allowances and other benefits - from Pôle emploi for unemployment, or from the CNAM itself for

disability pensions - are not accumulated. The information system does not provide alerts.

Insufficient monitoring to prevent and monitor pre-natal leave

Expenditure on pre-natal leave is not identified as such, and the corresponding durations

are included in the overall durations observed for maternity leave. Doctors are not required to

specify the reason for the leave they prescribe. The French health authority [

Haute Autorité de

Santé

] has not issued any recommendation concerning the prescription of pre-natal leave. Nor

does the CNAM medical service analyse the reasons for pre-natal leave.

This general lack of awareness of pre-natal leave is regrettable. The availability of data

would enable us to better assess the health of working women during and after their

pregnancy, and the possible links with premature newborns or disabilities at birth. The links

with commuting times or with working conditions by sector of activity should be studied, with a

view to prevention.

Recommendations

23.

Complete the transfer of funding for maternity and paternity leave to the family branch,

taking care to preserve the branch’s financial balance (Ministry of Solidarity, Autonomy and

for Persons with Disabilities, CNAM, CNAF).

24.

Develop statistical tools to monitor the health of pregnant women and the non-use of

maternity leave (Ministry of Solidarity, Autonomy and for Persons with Disabilities, CNAM,

CNAF).

25.

In order to improve monitoring and reduce delays in the payment of daily allowances, limit

information on pregnancy-related sick leave provided by employers to the online

declaration of employee information (DSN) (Ministry of Solidarity, Autonomy and for

Persons with Disabilities, CNAM).

26.

Align the duration of entitlement to adoption leave and pre-natal leave for non-salaried

workers with that of salaried workers (Ministry of Solidarity, Autonomy and for Persons with

Disabilities).

4 - Preventing benefit fraud: a more dynamic approach

that needs to be further strengthened

In September 2020, the Court of Accounts made around fifteen recommendations to the

Senate’s Social Affairs Committee on how to prevent benefit fraud more effectively. The Court

wanted to quickly examine the action taken on its recommendations and provide an updated

assessment of the measures taken to prevent fraud, in a context changed by new provisions

introduced by the LFSS, by administrative reorganisations and by the impact of the health crisis.

Numerous legislative measures, most of which have yet to be implemented

The latest social security finance acts have introduced a number of useful measures, but

some implementing legislation has yet to be published and some of the IT projects required to

implement these measures have yet to be finalised.

Administrative action under pressure

In December 2020, the Ministers for Health, Employment and Public Accounts entrusted

the Director of Social Security with a roadmap setting out five guidelines to prevent benefit

fraud

5

. Created in July 2020, the Inter-ministerial Anti-Fraud Coordination Mission (MICAF)

plays an active role in driving forward and coordinating fraud prevention.

5

20

Progress is still insufficient in assessing the amount of fraud

Since 2010, the CNAF has periodically carried out a robust assessment of statutory

benefit fraud (€

2.8bn in 2021).

The CNAV estimates the undue payments resulting from errors, but not specifically the

proportion of intentional fraud that may be involved. For beneficiaries of the basic old-age

pension, which is the main benefit for which the pension funds detect fraud and mistakes, the

condition of actual residence in France for six months is checked by detecting any anomalies

in the information available.

For its part, the CNAM has set 2024 as the deadline for completing the evaluation work

it has recently begun. This currently covers only 27 % of the total statutory benefits paid by the

health insurance scheme. Applying a simple rule of three to the amounts already estimated

gives a figure for fraud of between €

3.8bn and €4.5bn. Only by extending the work already

underway to the entire field of services (excluding fixed rates to health professionals and

budget allocations to institutions) will it be possible to obtain a rigorous estimate of the amounts

involved.

Substantial reinforcement of checks

Compared to the available estimates of fraud, the amounts of fraud actually detected by

the checks carried out by the social security funds are modest. The new agreements on

objectives and management (COG) must set them more ambitious targets.

Available estimates of benefit fraud

Estimated

amount of fraud

and errors

As a % of the

expenditure

concerned

Amount of fraud

and

errors

detected

%

detected

of

estimated fraud

and errors

CAF (2020)

€2.5bn to €3.2bn

3.1 to 4.0%

€0.3bn

11.0%

C2S (2018)

€177m

8.7%

€1.4m

0.8%

General

practitioners

(2018-2019)

€185m to €215m

3.1 to 3.5%

€3.7m (2019)

€4m (2018)

1.7 to 2.2%

Nurses (2018)

€286m to €393m

5.0 to 6.9%

€17.8m

4.5 to 6.2%

Masseurs-

physiotherapists

(2018-2019)

€166m to €234m

5.2 to 6.7%

€7.9m (2019)

€11.3m (2018)

1.8 to 2.8%

Pharmacists

(2018-2019)

€91m to €105m

0.5 to 0.6%

€4.3m (2019)

€4.7m (2018)

8.8 to 10.8%

Patient transport

(2018-2019)

€145m to €177m

3.9 to 4.9%

€6.9m (2019)

€12.3m (201

8)

4.8 to 6.9%

Pensions (2020)

€100m to €400m

0.1 to 0.3%

€19.7m

4.9 to 19.7%

Source: Court of Accounts, based on information from the CNAF (fraud), the CNAM (fraud and errors), and the CNAV (errors)

21

Priority actions

In particular, the health insurance scheme must endeavour to prevent overcharging by

health professionals and institutions, by upgrading its reimbursement management IT systems

so that they can automatically check invoices submitted to it. The digitalisation of medical

prescriptions will also make it possible to avoid incorrect payment for services that are not

consistent with prescriptions.

Recovery of incorrect payments is also a priority. The health insurance scheme must

make use of the option given to it by the 2023 LFSS to extrapolate, for both parties, the

incorrect payments found during a partial control, for the entire activity of a professional. The

family branch, for its part, will have to upgrade its information systems to recover incorrect

payments for all periods that are not time barred (five years or more), instead of two or three

years as at present.

All branches must take more decisive and robust action to punish the perpetrators of

fraud, particularly in the case of repeat offences.

The Court reiterates its previous recommendations and also makes four new ones.

Recommendations

27.

Publish regulations to ensure swift and full application of the organic and legislative

provisions published since 2020 to help prevent benefit fraud more effectively (Ministry of

Labour, Full Employment and Integration, Ministry of Health and Prevention, Ministry of

Solidarity, Autonomy and for Persons with Disabilities, Ministry of the Economy, Finance

and Industrial and Digital Sovereignty).

28.

Adapt information systems to identify and recover fraudulent payments for all non-time-

barred periods in accordance with the statutory rules in force (Ministry of Labour, Full

Employment and Integration, Ministry of Health and Prevention, Ministry of Solidarity,

Autonomy and for Persons with Disabilities, CNAF and CNAM).

29.

As part of the METEORe project to overhaul the computerised system for paying

healthcare costs, roll out automated checks to block the payment of all invoices issued by

health professionals and institutions that are irregular in relation to the tariff nomenclature

in force (Ministry of Health and Prevention, CNAM).

30.

In order to significantly reduce undetected fraud, from 2024, increase the number of

a

posteriori

controls to a level higher than that in 2019, before the health crisis (Ministry of

Labour, Full Employment and Integration, Ministry of Health and Prevention, Ministry of

Solidarity, Autonomy and for Persons with Disabilities, Ministry of the Economy, Finance

and Industrial and Digital Sovereignty, CNAF, CNAM and CNAV).

III - Necessary changes

The Court focused on four areas that have not been the subject of recent reforms or

measures as part of social security finance acts.

The inquiries carried out highlight the need to take better account of a wide range of

issues, whether these concern the conditi

ons required to make the health insurance system’s

actions on the appropriateness of medical procedures and prescriptions more effective

(Chapter VIII), the differences in retirement pensions between men and women (Chapter IX),

the management of the social security system for the maritime sector (Chapter X) or the

management of disputes between those insured and social security bodies (Chapter XI).

22

1 - Medical control of healthcare expenditure: an unsuccessful form of

regulation

At the turn of the 90s and 2000s, it became clear that if healthcare expenditure targets

were to be met, action needed to be taken on medical practices to encourage the use of the

least costly techniques, with equal effectiveness, and reduce the number of procedures

performed and products dispensed unnecessarily.

Medical control is part of risk management, alongside the fight against fraud and

prevention. It also aims to ensure that expenditure is appropriate, by trying to avoid

unnecessary use of care.

Risk management, medical control and appropriateness of care

Source: Court of Accounts

Medical control measures mainly take the form of information campaigns (letters) and

visits to health professionals by health insurance representatives and medical examiners, to

encourage them to improve their practices. They are not intended to punish professionals or

patients, unlike, for example, fraud prevention.

A narrow scope

To date, the scope of medical control has been narrow, essentially confined to medicines, either

to limit their prescription when they are not justified, or to encourage their prescription in the form of

cheaper generics or biosimilar medicines (the equivalent of generics for biological medicines). It has

only been applied to ONDAM expenditure on ‘primary care’, i.e. prescripti

ons issued by general

practitioners, specialists and dentists, as well as the increasing number of prescriptions issued in

hospital but provided in community pharmacies.

Savings targets poorly documented and results poorly backed up

While the Organisation for Economic Cooperation and Development (OECD) has

estimated that "around one-fifth of health expenditure makes no or minimal contribution to good

23

health outcomes

6

", an annual savings target of between €

700m and €

800m has been set for

the health insurance system. This target seems limited, given the above-mentioned ratio,

which would lead to between €

12bn and €

18bn of prescriptions of all kinds being dispensed

by general practitioners.

The financial return on the actions taken is assessed using questionable methodologies:

the figures for the savings envisaged are not based on a simulation or on a well-argued

forecast of the effects of the planned actions, which are not detailed. The amount indicated is

essentially based on a renewal of the target set the previous year. Medical control is thus

expressed as a macro-economic target, on a vague basis, which is supposed to secure the

ONDAM. Each year, the health insurance system produces a table showing the amount of

savings considered to have been achieved through medical control, broken down by type of

expenditure. However, the savings presented

7

should be read with caution.

Unconvincing calculation of results

According to annex 1 of the PLFSS, the savings attributable to medical control of healthcare

expenditure result from the difference between

“the trend amount”

, i.e. “

the amount that would have

been saved without intervention by the health insurance system”,

and

“the observed amount of health

insurance expenditure”

. However, no precise information is provided in support of the figures to

explain how the ‘trend’ is estimated, and how the proportion of savings attributable to medical control

measures is assessed.

Moreover, the savings made are generally lower than those announced in the initial PLFSS.

The calculation of the trend level of expenditure is also questionable. Finally, the way savings are

presented tends to attribute them entirely to medical control, whereas they may result from many

factors other than the streamlining of practices: demographics, epidemiology, and technical

innovations.

The impact of medical control seems limited with regard to international comparisons

which ranks France poorly compared with its European neighbours: despite thirty years since

its implementation, France’s annual per capita consumption of medicines is in line with the

OECD average ($589 in 2021), but it is still a long way behind the least expensive countries

($ 301 for Denmark, $

419 for the Netherlands), representing a difference of between €

11bn

and €

19bn.

Consumption of medicines: results are still inadequate

In France, generics account for 38 % of the total prescriptions of medicines (on and off the list

of generic medicines) in terms of volume (920 million boxes) and 19

% in terms of value (€

3.615bn),

compared with a European average of 60 % in terms of volume (80 % in Germany).

With regard to medicine prescriptions for elderly patients with multiple illnesses, the

REview of

potentially inappropriate MEDIcation pr[e]scribing in Seniors

(REMEDI[e S) study, carried out in 2021,

found that €657m of prescriptions were inappropriate (medicine not indicated for the diagnosis, or

even dangerous; dose too high; duration too lo

ng; duplication of medicines), of which €

507m was

reimbursed by the health insurance system and could therefore have been saved.

In addition to the adjustments recently implemented by the CNAM through its

‘Rénov’GDR’

programme

new impetus needs to be given to policies aimed at improving the

efficiency of medical practices. This presupposes the resolve to design and implement tools

that are currently lacking or underdeveloped, principally practice guidelines for health

professionals, as well as the coding of diagnoses and prescriptions in the form of structured

data to enable them to be used digitally, both by prescribing physicians and by the health

insurance system in the design and implementation of its control measures.

24

Recommendations

31.

Justify the savings expected from the medical control measures included in the Social

Security Finance Bill, specifying the cost drivers (price and volume) used to set the savings

targets, and detail the method used to calculate the results for the last known financial year

(Ministry of Health and Prevention, CNAM).

32.

Enhance medical and patient life data and organise it with a view to consolidating it at

national level, in order to improve medical control actions and their evaluation (Ministry of

Health and Prevention, CNAM).

33.

Make it compulsory to use electronic prescriptions, particularly for medicines and medical

devices, and to mention the medical indications justifying these prescriptions (Ministry of

Health and Prevention, CNAM).

34.

Enforce more rigorously the obligation for the prescriber to mention on prescriptions the

use of medicines outside the scope of their drug approval (‘outside drug approval’) and

provide a more precise framework for this use (duration, dosage, etc.) (Ministry of Health

and Prevention, CNAM, ANSM, HAS).

2 -

Women’s pensions: work to be continued on closing the gap with men’s

pensions

Persistent pension gaps

Although the law has set solidarity objectives for the pay-as-you-go pension system,

including ensuring equality between men and women, in 2020 the direct entitlement pensions

received by women were 40

% lower than those received by men (€

1,154 and €

1,931

respectively). However, differences in pensions have narrowed in recent decades.

Changes in differences in direct entitlement pensions

between men and women by generation

Note: the direct entitlement pension of women born in 1930 is on average 54% lower

than that of men. This difference is 42% for a ‘full career equivalent’,

i.e. if the period validated

under the scheme corresponds to the required period for the full rate.

Scope: pensioners resident in France who received a direct entitlement pension.

Source: DREES

Various causes

The main reason for this is that pension amounts are directly related to the length of time

people have worked and the income they have earned. However, despite significant progress,

there are still fewer women than men in work; those who are in work are three times more likely

than men to have a part-

time job, and women’s hourly wages are still lower than those of men.

25

Rising employment rates and persistent pay gaps

The proportion of women in work or unemployed has risen by 30 points since 1975, reaching 67.6 %

in 2020 compared with 74.5 % for men. Of these women, 27.4 % work part-time compared with 8.4 % of

men.

The average pay gap between women and men has narrowed slightly in 25 years, from 27.4 %

in 1995 to 22.3 % in 2019. Nearly three-quarters of these gaps reflect differences in hourly pay, with

the remainder reflecting differences in the number of hours worked in the year, due to the fact that

more women work part-time.

In addition to these main causes, there are the effects of the general rules for calculating

the pension amount, some of which have changed as a result of pension reforms since 1993.

The discount, which is applied when the beneficiary has not made the contributions required

to receive a full-rate pension, particularly penalises women, whose careers are more often

incomplete, unless they postpone their retirement age. Thanks to the rise in the female employment

rate, the gap between the average retirement ages of women born in 1950 (60.9) and men born in

the same year (60.1) has however been halved compared to the generation born 20 years earlier.

In addition, two rules introduced in 1993, which have since been used to calculate

pension entitlements, i.e. the best 25 years of salary and the indexation of these salaries to

inflation, are, in practice, unfavourable to beneficiaries with short careers and low salaries,

which is the case for the majority of women. On the other hand, the deferment of the statutory

retirement age and of the age at which the discount is abolished as a result of the 2010 reform,

as well as the extension of the insurance period required to retire at the full rate as a result of

the 2014 reform, have, according to a study

8

, helped to reduce the difference in pension

amounts, accumulated over the period of receipt, between men and women, from one point

for the 1960 generation to just over three points for the 1980 generation, at the cost of

postponing the average retirement age for women.

Solidarity and survivor schemes reduce the pension gap between men and women

The pension system’s solidarity schemes grant entitlements, in addition to those linked

to periods of employment, which are not in return for contributions paid by their beneficiaries.

Survivors’ benefits are different in that they can be considered as compensation for the

contributions paid by the couple.

Solidarity schemes have a significant effect on reducing the pension gap between women

and men. Without the solidarity schemes, the average direct entitlement pension of women

would have been 50

% lower than men’s, not 42

% as a 2016 study found. The difference (almost

11 points) in favour of women in the weight of these schemes in direct entitlement pensions (see

table below) is mainly due to family pension entitlement (difference of 10 points).

Almost 90

% of beneficiaries of survivors’ pensions are women, given the differences in

life expectancy and age within couples. In 2020, survivors’ pensions reduced the average

pension gap between women and men, from 40 % for direct entitlements to 28 % after

survivors’ pensions are taken into account. For those who receive it, i.e. one third of retired

women, the survivors’ pension represents on average around half of the total pension.

8

Les réformes des retraites de 2010 à 2015 : une analyse détaillée de l’impact pour les affiliés et pour les régimes

,

[Pension reforms 2010 to 2015: a detailed analysis of the impact for those affiliated and for the schemes], Les

dossiers de la Drees n° 9, December 2016.

26

Proportion of solidarity schemes in total direct entitlement pensions

under all schemes in 2016

As a % of total direct entitlement

pensions

Women

Men

Family pension entitlement

13.2%

3.2%

basic pension

6.2%

1.1%

Equivalent periods (unemployment,

sickness, maternity, incapacity)

4.7%

5.3%

Early retirement for long career

1.7%

2.6%

Other

3.3%

6.1%

Total of solidarity schemes

29.1%

18.3%

Source: Court of Accounts, based on DREES data

Costly systems with room for improvement

Family pension entitlement (m

ore than €20bn in 2021) and survivor benefits (€36bn) are

costly (18% of the total cost of pension benefits) and not very effective.

Family entitlements

9

do little to compensate for the impact of children on mothers’

careers: they award too many pension quarters (in which the individual has made pension

contributions) compared to reductions in work, while they do little to compensate for the

associated loss of earnings. As a result, at constant cost, these entitlements should be

adjusted in favour of pension increases and simplified, with a view to greater harmonisation

between pension schemes.

In addition, survivors’ benefits vary widely from one scheme to another. They do not

maintain the standard of living of women, whose direct entitlement pensions are the lowest.

The increasing prevalence of divorce also calls for a review of the current principle of prorating

the survivor’s pension in the presence of several spouses, which raises questions of fairness

between divorced women whose ex-husbands have remarried and who will only receive a

share of the survivor’s pension, and those whose ex

-husbands have not remarried and who

will receive the full amount in most schemes.

3 - The social security scheme for seafarers: an essential standardisation

process

Members of the special scheme for seafarers

34,000 working people are affiliated to ENIM as part of their professional activity. The

healthcare branch of the scheme has around 90,000 members, including 70,000 who are directly

insured and 20,000 dependants. The old-age branch of the special scheme pays pensions to around

65,000 direct pensioners (90 % of whom also receive pensions paid by other pension schemes for

other professional activities during their career).

27

Funding mainly from central government and the health insurance system

Of all the social security schemes with a significant number of active employees, it is the

most heavily subsidised: the scheme’s funding comes mainly from central government’s

budget for its pension expenditure (€

997m in 2021) and from the health insurance fund for its

benefits scheme (€

420m). The social security contributions paid by its contributors and their

employers account for only 10 % of its revenue.

Specific and complex regulations

Social security contributions are not based on actual salaries but on flat-rate salaries.

The flat-rate salaries are much lower than actual salaries in the maritime sector. For the retail

sector, actual remuneration was around €

650m in 2021, i.e. 2.5 times higher than that of the

flat-rate base for

this sector (€

253m). Gross earnings in the fishing industry are also higher

than the flat-rate base.

An obsolete classification system

Flat-rate salaries are divided into twenty categories, themselves determined by reference to

280 on-board positions, the list of which was laid down by a 1952 decree. Each seafarer must be

assigned to a category, and their position on board must be specified each time they board. The level

of their contributions and benefit entitlements acquired under the scheme depend on this. In practice,

the five main positions account for almost 40 % of the workforce affiliated to ENIM; 166 positions have

fewer than 200 seafarers and 79 positions have none. Some positions no longer exist but are still

included in the regulatory scale that has been fixed from the outset; others, which have since

appeared, are not provided for. The new international qualification requirements for renewing

maritime certificates have not been taken into account.

A non-standard pension scheme with sickness benefits partly aligned with those

paid by the general scheme

The actual technical return on the pension scheme can be in the region of 30%, which means

that the beneficiary recovers all the contributions paid during his working life in just three years

of pension payments

.

Very different rules for calculating pensions

Pensions under the scheme can be paid from the age of 50 after 25 years’ affiliation, regardless

of the sector of activity, the duties performed and the type of vessel or shipping. Half of the pensions

paid by ENIM are so-

called ‘special’ pensions, paid after the age of 55 for a short period of affiliation

(between 3 months and 15 years, with a median period of 3.5 years). Prior to 1987, when the minimum

qualifying period was reduced from 5 years to 3 months, most of these pensions were calculated

according to the rules of the general scheme and not the rules of the special scheme. Lastly, 26 % of

ENIM pension expenditure is attributable to survivors’ pensions, compared with an average of 11

%

for all pension schemes. This high cost is due to the fact that the vast majority of those insured are

men, who give their wives their entitlement when they die, but also to the fact that survivors’ pensions

are not subject to any age or means test, unlike other private sector pension schemes.

Reimbursements of healthcare costs are identical to those paid to employees under the

general scheme. On the other hand, daily allowances for sick leave are governed by complex

rules and are generally unfavourable in terms of the amount received and the time taken to

make payment (up to 20 days longer than under the general scheme). Despite a high accident

rate, the maritime sector is not covered by an occupational accident scheme that makes

employers liable.

28

The accuracy of contributions collected and benefits received has become

structurally uncertain

The management of the scheme has been profoundly destabilised by three recent

reforms, the first relating to the rules governing maritime traffic, the second to the transfer of

the collection of contributions due to ENIM to the Urssaf Poitou-Charentes on 1 January 2020,

and the third to the use of the employer’s online declaration of employee information (DSN).

As a result, the often outdated parameters needed to calculate contributions and cash benefits

paid by the scheme can no longer be collected under conditions that guarantee their accuracy.

Since 2017, the ‘service lines’ containing the information needed to calculate the

applicable flat-rate salaries and contribution rates have no longer been entered or checked by

the maritime affairs departments. Employers, for their part, have the greatest difficulty in

sending this information via the online declaration of employee information (DSN). Checks on

the declarations of employers and self-employed persons in the maritime sector are no longer

carried out.

Removal of checks on crew lists

Source: Court of Accounts

No longer possible to check salary declarations

Checking declarations in the maritime sector is an extremely complex task, requiring the

verification of 27 different points (on the characteristics of the seafarer, the employer and the vessel).

However, the way in which DSN data flows are organised between the Urssaf and ENIM has

resulted in the compartmentalisation of information to which each has access, making it impossible

to check individual declarations.

Comprehensive reform is essential

A comprehensive reform of the social security scheme for seafarers is now inevitable. It

will have to reconcile consideration of the different economic situations of the various sectors

that make up the maritime world with the many issues, such as protecting rights that have

already been established, fairness in relation to all social security beneficiaries, and the

arduous and dangerous nature of some of the maritime professions. To that end, the Court

makes a series of recommendations.

29

Recommendations

(Ministry of Labour, Full Employment and Integration,

Ministry of Health and Prevention, Secretary of State to the Prime Minister,

responsible for maritime affairs)

35.

Restructure the base for contributions to, and the acquisition of, social security benefits for

seafarers on the basis of gross income, while protecting pension rights previously built up

under the special scheme on the basis of flat-rate wages.

36.

Restore the five-year affiliation period below which seafarers are not eligible for the special

pension and introduce minimum age and income conditions for entitlement to the survivors’

pension.

37.

Affiliate seafarers to the healthcare branch of the general scheme, starting with benefits in

kind and continuing with cash benefits and cover for accidents at work and occupational

illnesses for working seafarers.

38.

Apply a single employer contribution rate to all maritime employers and provide for a

simplified system for reducing or exempting charges that can only be adjusted according

to the economic constraints specific to each maritime sector.

4 - Disputes between individuals and companies and the bodies of the general

social security scheme: more progress to be made

The Law of 18 November 2016 on the modernisation of 20th century justice radically

reformed the organisation of the handling of disputes between individuals and social security

bodies, which is now entrusted to the ordinary judicial or administrative courts.

Simplification of appeals

The

tribunal des affaires sociales

(TASS) and the

tribunal du contentieux de l’incapacité

(TCI)

have been abolished. From now on, the ordinary judicial court [

tribunal judiciaire

(TJ)] will handle

virtually all

social security disputes within a social division created for that purpose. As regards

litigation relating to State-funded benefits, the departmental welfare commissions have also been

abolished, with the administrative courts now dealing with litigation relating to State medical

assistance, alongside litigation relating to income support (RSA), the top-up benefit for low-paid

workers and personal housing benefit, for which they were already responsible.

In particular, this progress concerns professional risks: before the reform, the TASS judged the

extent of after-effects, whether they were attributable to an accident at work or an occupational illness,

, while the TCI had jurisdiction over

the degree of incapacity. It was common for the TCI to have to stay its proceedings pending the TASS

ruling, or for the National Court for Incapacity and Pricing of Workplace Accident Insurance [

Cour

nationale de l’incapacité et de la tarification de l’assurance des accidents du travail

(CNITAAT)] to

an appeal against the TASS ruling on whether the employer was responsible for the accident or

illness.

The transfer of social security litigation to the ordinary judicial courts also provides a solid

basis for the litigation of disputes: these courts are independent of the social security

authorities and are presided by a professional judge, and there is standardisation of funding

and jobs, which now come under the budget of the Ministry of Justice.

30

A reorganisation that is not yet finished

Following the 2016 reform, the judicial and administrative courts continue to have

jurisdiction under rules that are difficult for users to understand. Assigning all of the so-called

social benefit disputes to the judicial courts dealt with by the administrative courts would

simplify claimants’ access to justice.

Simplification to be completed

Beneficiaries of the family allowance fund (CAF) must apply to both the judicial courts and the

administrative courts if they dispute the reality of situations (in particular the composition and income

of the household) that affect both social security family benefits, for which disputes come under the

jurisdiction of the judicial courts, and those paid on behalf of the State or départements, which, with

a few exceptions (allowance for adults with disabilities), come under the jurisdiction of the

administrative courts (income support (RSA), top-up benefit for low-paid workers and personal

housing benefit).

The administrative courts deal with disputes relating to the rejection of applications for state-

funded medical aid by health insurance funds. However, these applications are investigated under

the same conditions as applications for mandatory basic health insurance and supplementary health

insurance.

In the field of disability, challenges to the decisions of departmental councils’ CAFs and

Committees on the Rights and Autonomy of Persons with Disabilities are divided between the judicial

and administrative courts in a way that is very difficult for claimants to understand.

Proceedings before the judicial courts and appeal courts are oral. Oral proceedings can

be detrimental to claimants if they do not have sufficiently well-founded arguments. While

companies often seek legal advice, this is much less common for individuals, despite their

fragile state of health or social situation. As has been the case for employment tribunal cases

since 2016, the introduction, at the appeal stage, of a written procedure with compulsory

representation by a qualified person would improve claimants’ arguments.

Performance is still insufficient

Despite an increase of more than 42 % in the number of active judges assigned to social

security litigation, the time taken to reach a decision at first instance has increased (24.1

months in 2021 compared with 17.6 months in 2019). For appeals, average processing times

have risen from 17.9 months in 2019 to 21.4 months in 2020 and to 23 months in 2021

(compared with 19 months in 2017 and 20.5 months in 2018 for the appeal courts and the

CNITAAT).

Pre-litigation organisation that can be improved

Before referring the matter to the judicial court, contributors and recipients of benefits

must in all cases submit their disputes in writing to the out-of-court appeal board [

commissions

de recours amiable

(CRA)]. These boards are made up of administrators (advisers for the

CPAMs) from the local general scheme funds. The matter must be referred to them within two

months of the contested decision. Their decisions, most often not in favour of the claimants,

are binding on organisations.

Simplification is necessary for pre-litigation concerning recovery of contributions

due by self-employed workers

Employers’ appeals in respect of social security charges and contributions are examined

by IDIRA (

instances départementales d’instruction des recours amiables

[departmental bodies

for examining out-of-court appeals]), which are part of the URSSAF departmental councils.

With a few exceptions, the URSSAF CRAs, which have regional jurisdiction, follow the IDIRAs’

proposals. The redeployment of contributor accounts between the departmental sites of the

regional URSSAFs and between the URSSAFs makes the departmental level of examining