PRESS RELEASE
12/10/2023
Public thematic report
PUBLIC AND PRIVATE ACUTE HOSPITALS, BETWEEN
COMPETITION AND COOPERATION
The French hospital system is made up of public and private acute hospitals. At the end of
2020, out of 2,989 establishments, there were 1,347 public hospitals, 972 private for-profit
and 670 private not-for-profit establishments, the majority of which were public-interest
private healthcare establishments (ESPIC). This report focuses on medicine, surgery and
obstetrics (MCO). In this field of activity, public hospitals provide 66 % of beds and places,
private for-profit 25 % and private not-for-profit 9 %. Based on the work of the Court of
Accounts and the regional audit chambers, this report analyses the characteristics of public
and private hospital provision, both for-profit and not-for-profit, the factors likely to
improve or penalize the efficiency of its organisation and overall performance, and the
means used by the regulatory authorities, at national and regional level, to best meet the
population’s hospital
acute care needs.
Regional disparities
Created by the law of 31 December 1970 as a whole, the
“P
ublic Hospital Service
”
was divided
into 14 functions by the law of 21 July 2009 (the “
Hospital, Patients, Healthcare, Territories
”
law), then reorganised in 2016 by the so-called
Touraine
law
in the form of a “
block of activities
”
carried out exclusively by public hospitals
and by the ESPICs. The legal concept of “
healthcare
establishment
”, established in 1991 by the
so called
Évin law
, introduced the principle of rules
and duties common to all three categories of establishment. However, funding arrangements
remain very different and still do not reflect clear, consistent principles. As a result, public and
private hospital services have continued to develop separately. Since 2014, competition for
short stays has intensified in metropolitan areas, while the public sector is increasingly, and
almost exclusively, covering needs throughout the country and remote areas, and providing
care for the most severe conditions, or in the most difficult social contexts. However, these
observations about the national average are clouded by a detailed regional analysis, which
reveals significant differencies. The majority of surgical services are private and, in some poorer
areas, private healthcare establishments cater for more beneficiaries of supplementary social
security health insurance (CSS) than public establishments.
Differences in status and business model continue to play a decisive role
The cost of care covered by the public health insurance system is still based on two different
pricing scales depending on the public or private status of the hospital, in particular because
the cost of care provided in public sector and private not-for-profit establishments includes the
remuneration of salaried doctors, whereas in the private for-profit sector, the fees of self-
employed doctors are covered separately. The resources of public healthcare establishments
are increasingly made up of financial endowments from the health public insurance scheme
decided by the regional healthcare agencies (ARS), from which private healthcare
establishments do not benefit or benefit very few. Moreover, social security and tax regimes
give the public sector a significant advantage over the private not-for-profit sector, for
comparable duties and patients. The historical concept of the
“P
ublic Hospital Service
”
,
originally reserved for public establishments and certain individually-authorised private not-
for-profit establishments, has gradually become blurred. Public sector practitioners may, under
certain conditions, operate private practices within public hospitals, charging fees that are
higher than the standard rates. Clarification has become necessary throughout the country in
order to match the need of the patients about the availability of hospital care under financial,
geographical and time conditions that meet equally their needs, regardless of the status of the
establishment able to provide them with care.
Acute healthcare licenses delivered to public and private hospitals must be more consistent
with the
“P
ublic Hospital Service
”
The reform of the system of licenses granted by the regional healthcare agencies (ARS), which
has been underway for the past two years, has not fully met requirements. Admittedly, the
technical and activity requirements for licenses have been tightened. However, the benefits for
the patients, particularly in terms of financial and geographical availability, should be much
better taken into account. In addition, when licenses are granted to entities managing private
establishments, commitments to stability and advance notice before modification or closure of
the provision of care should be required. With regard to the relevance of acute hospital care,
the extent of the discrepancies observed between practices in certain departments and the
national average requires an analysis of atypical activities, in the light of best practice
guidelines, to be carried out by the Ministry of Health. Such an analysis would provide a better
basis for the policy of each regional healthcare planning, as well as for decisions to grant
licenses for healthcare activities.
Given the difficulties encountered in terms of hospital provision in a large part of the country,
and taking into account the importance of stimulating competition to improve the quality of
care and patient satisfaction, , the regional health authorities should make a much better use
of, or strengthen, their means to encourage, or even force, operators and practitioners to
cooperate more fully, based on the renewed role of the
“P
ublic Hospital Service
”
, which is
currently insufficiently coordinated with the licenses granted. A simple rule could prevail: any
public or private hospital licensed and financed by public support must participate in the
effective implementation of an efficient
“P
ublic Hospital Service
”
in their relevant area,
according to its capacity, the medical specialties it provides and in response to the specific
needs of patients.
Read the report
PRESS CONTACT:
Julie Poissier
◼
Head of Press Relations
◼
T
+33(0)6 87 36 52 21
◼
julie.poissier@ccomptes.fr
@Courdescomptes
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