C
OUR DES
C
OMPTES
Social security
T
his summary is designed to make the Cour des
Comptes report easier to read and use.
The Cour des Comptes is responsible only for the
content of the report.
The responses of government departments,
councils and other organizations are appended to
the report.
Notice
Summary
2012 report on the application of the laws for
financing social security
September 2012
Introduction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Part one - The accounts and financing of social security
1
- The deficits and debt of the social security system:
2011 situation and perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
2
- The national objective for healthcare insurance spending
in 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3
- Opinion of the Cour des Comptes on the coherence of the
balance sheet tables and asset table for 2011 . . . . . . . . . . . . . . . .17
4
- Certification of the accounts of the general social security
scheme by the Cour des Comptes: an initial assessment . . . . . . .21
5
- Financing social security through taxes . . . . . . . . . . . . . . . . . .25
Part two
-
Difficulties in implementing certain reforms
6
- Reform of the SNCF and RATP pension schemes . . . . . . . .29
7
- The social security scheme for self-employed workers and the
system for collecting their contributions . . . . . . . . . . . . . . . . . . . .33
8
- The establishment of ARS . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Part three - The efficiency of the health care system
9
- The role of the ONM in organising health care
and upholding medical ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Summary
of 2012 social security report
3
Contents
10
- The health insurance system’s payment of social security
contributions for self-employed health care professionals . . . . . .45
11
- Patient transport costs paid by the health insurance system . . . . . . 49
12
- Aftercare and rehabilitation
. . . . . . . . . . . . . . . . . . . . . . . . . .53
13
- Certification of hospitals by the French National Authority
for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Part four - Solidarity with retired people and families
14
- Old-age coverage for the poorest people
. . . . . . . . . . . . . . .61
15
- Specific tax and welfare measures for retired people . . . . . .65
16
- The redistributive function of means-tested
family benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Part five - Improvements required in social security
management
17
- Direction and management of the information system of the
general scheme’s Family Division
. . . . . . . . . . . . . . . . . . . . . . . . .73
18
- Daily sickness benefits paid by the general scheme
. . . . . . .77
Contents
4
The annual report on the application of social security financing laws presents
the results of the work carried out by the Cour des Comptes on social security.
Social security accounts that are unbalanced in the long-term and require a wide
ranging effort
The deficit of the general scheme and old-age solidarity fund (
fonds de
solidarité vieillesse
, FSV) showed a decrease in 2011 but remained very high,
despite compliance with the national objective for health insurance expenditure (
objectif
national des dépenses d’assurance maladie
, ONDAM) for the second consecutive
year. At -€20.9 billion, it is more than double what it was for 2007-2008. Based on
its work of certifying the accounts of the general scheme, the Cour des Comptes has
issued its opinion on the balance sheets and asset table attached to the draft social security
financing law that confirm the extent of deterioration in the social security accounts.
The majority of the work required to balance these accounts remains to be done.
For 2012 and subsequent years, despite new revenues approved over the summer,
forecasts are for deficit reduction to slow down, with a general scheme deficit nearly
€1 billion higher than forecast in the 2012 financing law and the need to take on new
debt on behalf of the health care and family divisions, which are likely to exceed
€9 billion. Nearly €60 billion in social security debt could accumulate between now and
the end of the decade, over and above the €62 billion that the law has already set aside
to transfer to the social security debt reimbursement fund (
caisse d’amortissement
de la dette sociale
, CADES) on behalf of the old age division and FSV between
2011 and 2018.
If a committed effort towards recovery is not implemented quickly, social security
debt will continue to grow even though it constitutes a serious anomaly and cannot
continue to be passed on to future generations. All public tools should be used to act.
In an attempt to make choices clearer, this report from the Cour des Comptes has
reviewed €80 billion in revenues and €40 billion in expenses.
Summary
of 2012 social security report
5
Introduction
Reforms with uncertain effects
The Cour des Comptes has investigated the contribution of organisational and
structural reform in balancing social security finances.
The financing of social security through dedicated taxes represents 12% of
revenue from basic schemes and, along with social security contributions and the general
social contribution, constitutes the third pillar of social security resources. A
comprehensive discussion is required to clarify the place of this unstable bundle that does
not favour accountability in the system for financing social security.
The reform of the special pension scheme for the SNCF and the RATP has
partly achieved its aim of harmonisation with the civil service, but with high additional
costs for companies, and a very limited effect on balancing the schemes. The creation of
a social security scheme for self-employed workers at the end of 2005 and the
establishment of a single system for collecting contributions caused major problems for
many people insured by the social security system and resulted in a reduction in revenue
(€1-1.5 billion by the end of 2010), with a negative impact on social security accounts.
The regional health agencies created in 2009 have been installed in satisfactory
conditions, but less centralised management, progress in positioning and appropriate
resources are essential for them to be fully successful in their missions, especially
improving follow-up care and rehabilitation, which should cost the health care insurance
system (
Assurance maladie
, AM) €7.8 billion in 2012.
Multiple tools for optimising the health care system
AM’s assuming responsibility for social security contributions of registered
independent health care workers should be used more proactively to achieve AM’s main
objectives; in particular, improved distribution of health care professions and limiting
exceeding standard fees.
The role of the French National Medical Association
(Ordre national des
médecins, ONM
) in ethical oversight and tact in determining fees is too limited a scope.
For the transport of patients covered by AM, the Cour des Comptes estimates
possible savings of at least €450 million per year, or 13% of overall expenditure
(€3.5 billion) that continues to grow.
The certification of public and private hospitals by the French National Health
Authority (
Haute autorité de santé
, HAS) has shown marked progress but its selection
and how it is taken into consideration in hospital performance contracts can be improved.
Summary
of 2012 social security report
Introduction
6
Summary
of 2012 social security report
Solidarity with retirees and families
The Cour des Comptes has analysed the contrasting conditions of retired people.
The minimum old-age pension plays an essential role in limiting poverty levels among the
the most vulnerable retirees, which makes it imperative to resolve the imbalance in the
FSV that funds it. From an overall financial perspective, however, the retired population
is currently in a slightly better situation than the working age population, especially the
youngest group. The Cour des Comptes thus believes it necessary to reconsider certain tax
expenditures and social niches that benefit from the current system, whilst protecting the
most vulnerable retired individuals, in order to redirect resources towards those currently
in need of support.
For family policy, the Cour des Comptes recommends an overall economic review
of all supports that are limited by resources, which are found to have a limited effect
in terms of reducing income inequality.
Savings required in social security management
The Cour des Comptes examined the information systems of the family division
of the programme and recommends an in-depth redefinition of its strategic aims and
how it is directed and managed. Regarding the system of daily allowances for illness,
provided by the general scheme (€6.4 billion in 2011), it proposes a much firmer
strategy for beneficiaries, companies and the medical sector, as well as further
simplification and stepping up audits and the battle against fraud.
***
Substantial progress in improving the efficiency of social security spending is also
possible on all levels. Achieving these improvements is essential. A voluntary, rigorous,
methodological and attentive approach requiring equal effort by all involved is required.
The more firmly it is applied, the faster social security accounts can be rebalanced, and
the better and more stable our social security system will become, not just in financial
terms but with regards to the basic values of solidarity that are associated with the
system.
Introduction
7
9
Summary
of 2012 social security report
Cour des Comptes
1
The deficits and debt of
the social security
system: 2011 financial
position and forecasts
Deficits in 2011 remain
massive but are declining
After reaching an unprecedented
level in 2010 (-€28 billion), or 1.4% of
GDP, the deficit of the general scheme
and the old-age solidarity fund (
fonds de
solidarité vieillesse
, FSV) began to decline
in 2011.
However, it remained particularly
high: at -€20.9 billion (1% of GDP),
it is more than double what it was in
2007-2008.
This improvement in the financial
position observed in 2011 is primarily
due
to
contributions
from
new
resources and a resistant wage bill,
although a certain degree of constraint
in spending also contributed, including
compliance with the national objective
for
health
insurance
expenditure
(ONDAM). The new measures for
revenue assigned to the general scheme
and FSV (€7 billion) represent almost
the entirety of the deficit reduction
(€7.1 billion).
2011
2010
Reduction
Health care
-8.6
-11.6
3
Work accidents
-0.2
-0.7
0.5
Family
-2.6
-2.7
0.1
Old-age
-6.0
-8.9
2.9
General scheme
-17.4
-23.9
6.5
FSV
-3.5
-4.1
0.6
RG + FSV
-20.9
-28
7.1
Situation of general scheme and FSV accounts (in billions of euros)
Source: accounts of general scheme and FSV
The deficits and debt of
social security: 2011 financial position
and forecasts
10
Summary
of 2012 social security report
The majority of the work required
to rebalance the social security accounts
remains to be done:
- the deficit of the general scheme
alone was exceptionally high for 2011
(-€17.4 billion or 0.9% of GDP). Two-
thirds of this deficit is structural, which
remains at the average rate it has been
for the last decade;
- FSV remains a strong concern: its
deficit (€3.5 billion) represented 19.7% of
the net expenditures in 2011. Despite the
contribution from new revenue, it will
increase
again
in
2012
(to
€4.1 billion according to latest estimates);
-
certain
schemes
have
also
experienced structural imbalances: the
pension scheme for local communities
and hospitals (CNRACL), the old-age
division for agricultural workers and the
miners’ scheme.
Continual growth in social
debt
Social security debt is mainly
covered by CADES and the central
agency for social security organisations
(
Agence Centrale des Organismes de Sécurité
Sociale
, ACOSS).
Despite
CADES
taking
on
€65.3 billion of accumulated deficits
from previous years, the most it ever
has, social security debt has started to
increase again.
The transfer of part of these
deficits (from old-age insurance and
FSV) to CADES has already been
planned for and financed, but this is not
the case for the deficits of the health
care and family divisions. In 2012 the
latter should reach more than €9 billion,
which has not been planned for.
More debt will need to be taken on
immediately after the end of the 2012
tax year. This will require further growth
in resources for CADES: if, as the Cour
des Comptes previously recommended,
it were raised by a rate corresponding to
employee contributions towards the
reimbursement of social security debt
(
contribution au remboursement de la dette
sociale
, CRDS), it should increase from
0.50% to 0.56%.
A situation that remains
particularly concerning
Deficits that will remain high in 2012
The Cour des Comptes has updated
the forecasts as of 1 September made at
the start of July in its report on the
financial position and forecast for public
finances. Despite the new revenues that
were approved over the summer, and
despite it seeming that the ONDAM
will be met again, the deficit of the
general scheme should be, all other
things remaining the same, €14.7 billion.
This level is higher than planned by the
social security finance law (
loi de
financement de la sécurité sociale
, LFSS) for
2012 (€13.8 billion), and is just
€2.7 billion lower than it was for 2011.
The FSV deficit should be kept to
€4.1 billion, as planned by the LFSS.
The effects of a degradation in
The deficits and debt of
social security: 2011 financial position
and forecasts
11
Summary
of 2012 social security report
employment should be compensated for
by more revenues from increasing the
flat-rate contribution.
In the medium term, rebalancing requires
new relief measures
Based
on
prudent
economic
assumptions and integrating the revenue
measures approved during the summer
of 2012, the Cour des Comptes has
attempted to clarify the position of
social security accounts in the medium
term:
- the annual deficit of old-age
insurance and FSV would continue
after 2018 at a level of around
€9 billion, far from the balanced
budget that the retirement reforms
aimed to achieve for by date;
- achieving an annual balance for
health insurance (
Assurance maladie
, AM)
without further expanding mandatory
contributions depends on the effort to
achieve the ONDAM: an annual growth
rate of 2.4% would allow a return to
balance in 2017, a growth rate of 2.7%
would push it back to 2019;
- the annual deficit of the family
division, which faces a progressive
reduction in resources, partly due to the
transfer of non-permanent resources
should, all other things remaining equal,
stabilise at around €2 billion.
In the absence of complementary
relief measures, and in a scenario where
the ONDAM increases by 2.7% per
year, this would likely mean that by the
end of the decade social security debt,
within the scope of the general scheme
and the FSV, would increase by around
€60 billion over and above what the law
has already planned to transfer to
CADES.
Therefore, it is imperative that plans
be implemented from 2013 for CADES
to take on the 2012 general scheme
deficit and to continually make a
concerted, committed effort to cut
spending.
1. Arrange that at the closure of
the 2012 financial year CADES take
on the 2012 health care and family
division deficits from the general
scheme by consequently increase the
CRDS rate.
2. Increase control over social
security spending, specifically for AM
and
increase
receipts
by
acting
primarily
on
social
niches
(recommendation reiterated).
3.
Cease
structural
underfinancing
of
FSV
(recommendation reiterated).
Recommendations
13
Summary
of 2012 social security report
Cour des Comptes
2
The national objective for
health insurance
expenditure in 2011
Created in 1996 to regulate health
care spending financed by social
security, the national objective for health
insurance expenditure (ONDAM) is set
each year by the social security financing
law.
Meeting the ONDAM for
the second consecutive
year
The growth of the ONDAM for
2011 was set at 2.9% (compared to 3%
in 2010), translating to a figure of
€167.1 billion. This target corresponds
to additional spending of €4.7 billion
for 2011. For the second consecutive
year, and for only the third time since it
was created, spending has stayed within
this target, and was even as much as
€0.5 billion below the objective. This
positive result has contributed to
initiating the reduction in social security
deficits observed in 2011.
Better and firmer
management
The new ONDAM governance,
established during 2010 was in full effect
for all of 2011.
The
role
of
the
monitoring
committee, composed of qualified
persons, was enlarged, with the decision
that it provides an additional two
reports per year. Monitoring the
ONDAM has been improved by
establishing a group that tracks statistics.
Lastly, a steering committee uses all of
the information to make the necessary
decisions. The desire for tight control
over health insurance spending gives
rise to a number of measures:
- funds were set aside as a
precautionary measure at the start of
the project (for a total of €530 billion);
- some funds, mainly concerning
health
establishments,
have
been
cancelled (€338 million);
- some new measures were not been
implemented (€420 billion), and as such
revalorization of professional health
care acts has been limited to the
consulting of general practitioners;
-
cost-saving
measures
passed
during the creation of the ONDAM
have been subjected to close monitoring
(they represented a total sum of
€2.35 billion or 98% of measures).
The national objective for health
insurance expenditure in 2011
14
Summary
of 2012 social security report
Despite this progress,
there are some limitations
regarding meeting ONDAM
The effect of a suitable design
ONDAM performance in 2011 has
benefited from the overestimation of its
base (anticipated expenditure for 2010).
If various measures did not cancel out
the effect, by maintaining an under-
execution of the ONDAM in 2011 by
the same amount, ONDAM growth
would not have been limited to the
objective of 2.9% but would have
reached 3.2%. This underexecution
compensated for the effects of the
overestimation of expenses in 2010 by
the same amount.
Additional elements to take into account
Work to identify and reassign all
unregulated spending in the scope of
the ONDAM should be carried out.
The report from the commission of
social security accounts should report
on the execution of the ONDAM over
three years, in order to integrate the
results of the conclusions of provisions
initially accounted for.
An effort to maintain
The favourable effect associated
with the overestimation of basic
spending created the same risk for
exceeding the ONDAM in 2012.
Without regulation, if there had
been strict compliance with amount of
forecast expenses, the effective growth
rate would be 2.7% rather than 2.5% as
set by the social security financing law.
The complete implementation of
savings initially planned and very
prudent management of frozen funds
are thus required to effectively limit
growth in ONDAM to 2.5% in 2012.
The national objective for health
insurance expenditure in 2011
15
Summary
of 2012 social security report
Recommendations
4. Provide a legal foundation for
the steering committee and give it the
priority of compliance with the total
and growth rate for ONDAM.
5.Prepare a shared, transparent
approach for preparing the ONDAM
under
the
management
of
the
monitoring committee.
6. Systematically evaluate the
accuracy of forecasts made during
preparation of the ONDAM.
7. Report on execution of the
ONDAM
based
on
multi-year
monitoring the final outcome of
provisions.
17
Summary
of 2012 social security report
Cour des Comptes
3
Opinion of the Cour des
Comptes on the balance
sheets and asset table
for 2011
The balance sheets and asset table
for 2011, prepared by the ministry
responsible for social security, are
subject to approval by the Parliament as
part of the draft social security
financing law (PFLSS) for 2013. In
accordance with the texts, the Cour des
Comptes has checked their coherence.
A coherent view of the results and of the
national situation
- balance sheets:
The balance sheets delineate the
revenues, expenditures and results of all
social security schemes that belong to
the divisions of the general scheme and
FSV.
The results of all basic obligatory
schemes, the divisions of the general
social security scheme and FSV given in
the balance sheets are characterised by
massive deficits, although they are below
the historic levels of 2010:
2011 Deficit
2010 Deficit
Obligatory basic schemes
-€19.6 billion
-€25.7 billion
General scheme
-€17.4 billion
-€23.9 billion
FSV
-€3.5 billion
-€4.1 billion
Results for social security schemes
Source: ministry responsible for social security
Opinion of the Cour des Comptes
on the balance sheets and asset
table for 2011
18
Summary
of 2012 social security report
- asset table
The aim of this document is to
improve information supplied to the
Parliament about the financial position
of entities covered by the social security
financing law (different from the
balance sheets, because they also include
the social security debt reimbursement
fund (CADES) and the pension reserve
fund (
fonds de réserve pour les retraites
,
FRR).
Taking the deficits into account, the
overall debt of these entities, as laid out
in the asset table, shows a new increase
from the previous financial year.
The net financial liability of social
security
increased,
amounting
to
€111 billion on 31 December 2011, or
5.5%
of
GDP,
compared
with
€96 billion on 31 December 2010, or
4.9 % of GDP. The increase in this
liability over the previous year is mainly
a result of the deficits in the divisions of
the general scheme and the FSV for
2011, of which a large part is financed
by CADES.
Financial statements of
social security schemes
remain unsatisfactory
The opinions expressed by the
external auditors of the divisions and
the collection activity of the general
scheme (Cour des Comptes) and part of
the other schemes and national social
security organisations (
commissaires aux
comptes
) indicate that the financial
statements of this category of pubic
administration have not yet achieved the
required standard. In particular, the
Cour des Comptes refuses to certify the
accounts of the family and work
accidents
-
occupational
diseases
(
accidents de travail - maladies professionnelles
,
AT-MP) divisions of the general
scheme; the accounts of self-employed
workers scheme have once again been
refused certification by their auditors.
On one hand, the reasons for this
refusal and the reservations expressed
by the external auditors have a direct
affect on the level of results and on the
evaluation of non-financial assets and
liabilities that are respectively provided
in the balance sheets and asset table.
To a lesser extent, the lack of
reconciliation
of
certain
inter-
institutional transactions also suggests
the existence of failings in the financial
state of certain organisations.
Need to improve
information provided to
Parliament
The information provided to the
Parliament
regarding
the
financial
situation of social security in the asset
table is detailed and relevant. However,
the quality of information provided by
the balance sheets remains insufficient.
The annex to the draft social
security financing law that aims to
clarify
the
revenues
and
the
expenditures indicated for the overall
figure in the balance sheets:
Opinion of the Cour des Comptes
on the balance sheets and asset
table for 2011
19
Summary
of 2012 social security report
- does not provide sufficient detail
regarding what composes revenues and
expenditures, which remain too grouped
together;
- does not allow the understanding
of withdrawals made by the minister for
social
security
for
revenues
and
expenditures
which
are
part
of
accounting by the schemes;
- does not show the variations in
revenues and expenditures (in amount
and percentage) and does not provide
any explanation for the causal factors.
Recommendations
8. Provide,
within
the
framework of annex 4 of the draft
social security financing law (
projet de loi
de financement de la Sécurité sociale
,
PLFSS),
information
on
the
composition and variation in revenues
and expenditures taken into account in
the balance sheets that have the same
quality with that procured for annex 9
regarding the assets and liabilities
detailed
in
the
asset
table
(recommendation reiterated).
9. Ensure the homogeneity of
accounting methods used for inter-
institutional
transactions
involved
within the scope of the balance sheets
and asset table (recommendation
reiterated).
10. In preparing balance sheets,
eliminate internal transfers and cease
contracting revenues and expenditures
that exceed the regulatory framework
established by the organic law relating
to the organic social security financing
law (
loi organique relative aux lois de
financement de la Sécurité sociale
, LOLFSS)
for preparing social security accounts.
Failing this, describe, in annex 4 to the
PLFSS,
the
impacts
that
this
contracting has on the development of
products and charges in relation to
those effectively accounted for in the
social security scheme (recommenda-
tion reiterated).
21
Summary
of 2012 social security report
Cour des Comptes
4
Certification of the
accounts of the general
social security scheme by
the Cour des Comptes: an
initial assessment
In order to assist the Parliament and
the government in the control and
application of the laws for financing
social security, since 2006 the Cour des
Comptes has verified the frequency,
integrity and reliability of division
accounts (healthcare, AT-MP, family and
old-age)
and
the
recovery
effort
performed by the general social security
scheme. The Cour des Comptes sought
to prepare an initial balance sheet for
the certification of the general scheme
accounts at the end of the second
triennial audit cycle.
A major contribution to
the quality of public
accounts and an
improvement in the
management of social
security
The work performed by the Cour
des Comptes for this audit focuses on
four issues: the risks of errors affecting
operations performed and accounted
for within the applicable legislation
regarding deductions and benefits; the
risks of errors affecting the accounting
results
recorded
with
regard
to
operations performed; the risks of over-
or underestimating results; and the
quality of the financial information.
In revealing the recognised or
potential risks for errors in accounts,
certification constitutes a powerful tool
for improving the reliability of the
accounts and, beyond this, progress on
larger issues: correct application of
decisions by the legislator and regulating
authority; equal treatment and the actual
quality of the service provided to
people receiving support and those
responsible
for
social
security
contributions;
and
making
social
security revenue and expenditure more
secure.
Important progress
The four national organisations in
the general scheme have committed to
take action, some of them committing
to significant action, aiming to reduce
financial risks that the Cour des
Comptes has noted are not sufficiently
covered by internal audit mechanisms.
Correct integration within the general
accounting of information regarding
Certification of the accounts of the general
social security scheme for the Cour des
Comptes: an initial assessment
22
Summary
of 2012 social security report
actions
performed;
incorrect
attribution, attribution of an incorrect
sum or the absence of attribution of
benefits; and the failure to be exhaustive
in
collecting
social
security
contributions.
The first six certifications resulted in
improvements that were often notable,
especially when the divisions committed
to overhaul their applicable systems for
internal control (which was the case for
all), if they have additional accounting
systems allowing them to support
accounting entries (healthcare division)
or whilst they have produced supporting
elements that can partially compensate
for the absence of correct accounting
records (recovery effort).
Uneven progress
However, the tasks that have been
undertaken did not all provide positive
results and progress is uneven.
Not all bodies have adopted the
certification process with the same
determination. If it is used as a catalyst
by ACOSS, and to a lesser degree by the
national fund for workers’ health
insurance (
caisse nationale d’assurance
maladie des travailleurs salariés
, CNAMTS),
the national fund for workers old-age
insurance (
caisse nationale de l’assurance
vieillesse des travailleurs salariés
, CNAVTS)
has been slow in implementing the
required work. For the family division,
the reform of the internal control
mechanism, the limitations of which
caused the Cour des Comptes to refuse
to certify the financial condition for the
2011 financial year, is a pre-requisite for
any real progress.
In addition, within a large number
of
constituent
organisations,
certification is still too often considered
to be a task that is only for accountants,
although it primarily concerns directors
and the departments they manage.
Current progress that has been
made
has
not
led
to
complete
certification of the financial statements
of the general scheme, that is to say that
the Cour des Comptes has not been able
to declare that it believes it has
reasonable assurance that there is no
significant error affecting results. As
such, the Cour des Comptes has refused
to certify the accounts of the family and
AT-MP
divisions
and
has
noted
reservations in certifying the accounts
of the healthcare and old-age divisions
as well as the recovery effort for the
2011 fiscal year.
The national organisations, as well
as their governing authorities (the
ministries responsible for social security
and the budget), should thus make a
more resolute effort to progressively
increase reserves as recommended by
the Cour des Comptes, by speeding up
the implementation of changes required
to make revenues and expenditures
more secure.
Certification of the accounts of the general
social security scheme by the Cour des
Comptes: an initial assessment
23
Summary
of 2012 social security report
Blockages in accounting to
be resolved
The financial state of the general
scheme continues to include omissions
or faults which require ministerial
decisions for correction:
- merging FSV with CNAVTS is
required to provide a reliable picture of
the deficit of the old age division, which
is currently underestimated in relation to
its resources (taking into account the
structural deficit of the FSV, the old-age
division does not record some products
until the following financial year);
-
the
principle
of
registering
accounts on an accrual basis is not fully
respected:
some
products
(social
contributions of self-employed workers,
taxes recovered by state services) are still
recorded on a cash basis, the provisions
for risks and expenditures are still
recorded in an incomplete manner
(which constitutes the main reason for
refusing to certify the 2011 accounts for
the AT-MP division) and the annexes to
accounts do not mention the significant
multi-year commitments given out in
the form of benefits (particularly
pensions);
- direct allocation of expenditures to
its own funds and processing the
financing of overtime pay (recording of
revenues that are allocated to the
following financial year) constitute other
sources for errors affecting results.
Recommendations
For ministries responsible for
social security and the budget
11
.
Define, through regulation,
objectives and precise rules that can be
enforced through internal control
mechanisms within all constituent
organisations and national funds in
compliance with requirements for
certification.
12
.
Integrate the FSV within the
scope of the old-age division of the
general scheme.
13
.
Remove factors blocking the
processing
accounts
of
certain
operations or situations (social security
contributions
of
self-employed
workers, dedicated taxes, provisions
for AT-MP disputes and multi-year
commitments regarding social security
benefits).
25
Summary
of 2012 social security report
Cour des Comptes
5
Financing social security
through taxes
Separate
from
social
security
contributions and the general social
contribution (
contribution sociale généralisée
,
CSG), dedicated taxes (
impôts et taxes
affectés
,
ITAF)
for
social
security
amounted to €54 billion in 2011. They
could reach nearly €60 billion in 2013
with the finance law amendment of
16 August 2012.
ITAF constitute the third
pillar for financing social
security
These taxes represent 12% of
receipts for the social security basic
schemes in 2011, after social security
contributions (64%) and the CSG (16%)
and includes around fifty different taxes.
The ten main taxes constitute 85% of
the total and the three largest, 61% (tax
on income, taxes on tobacco and VAT
on certain products).
Long
limited
to
schemes
for
independent workers, ITAF increased
between 2000-2010 to compensate for
the increasing cost of reductions to
social security contributions, reduce
deficits and finance social security debt.
The general scheme is now the main
beneficiary of ITAF (75% of total
revenues), even if the schemes for self-
employed workers and agricultural
workers still benefit from significant
fiscal resources. In terms of divisions,
family and healthcare insurance are the
greatest beneficiaries.
Financing of
social security from taxes
26
Summary
of 2012 social security report
Share of ITAF in the resources of all the basic schemes
2011
All divisions
11.8
Healthcare
14.7
Old-age (except for ITAF to FSV)
8.4
Family
15.1
AT-MP
1.5
Limited improvements in
terms of diversifying the
base and strength in
contributions
ITAF is based on consumption
(49% of 2011 total, €26.4 billion), far
ahead of salary (26%, €14 billion),
companies (19%, €10.2 billion) and
capital (5%, €2.9 billion).
In the long term, the overall
movement of the ITAF is similar to the
other sources of finance for social
security and is not, as such, in a position
to speed up the balancing of social
security
accounts.
The
dynamics,
however, vary by controlling schemes or
divisions, to the detriment of the family
and
old-age
agricultural
workers
divisions.
An unstable system that
does not promote
accountability
The incessant changes to ITAF over
the last 10 years (distribution over the
divisions, creation of new taxes) have
not contributed to making finances
attributed to the social sector secure.
Furthermore, as opposed to the CSG
and CRDS, the ITAF lack transparency
for those who pay for and those who
benefit from them. As can be seen from
the companies’ social contribution
(
contribution sociale de solidarité sur les
sociétés
, C3S) designated for the self-
employed workers scheme (
regime social
des independants
, RSI), and since 2011 to
the agricultural scheme (
mutualité sociale
agricole
, MSA), the system negatively
impacts accountability.
Source: PLFSS data, Cour des Comptes calculations
In %
Financing of
social security from taxes
27
Summary
of 2012 social security report
It is essential that this
system be rapidly
restructured
In the current situation where the
movement to associate social protection
with taxation will probably last for some
time, this third pillar for financing now
requires essential choices to be made so
the methods for distribution and
changes in its resources can be more
clearly defined.
Without neglecting the priority of
controlling spending, and with an
approach of standardised obligatory
contributions,
different
paths
to
achieving this should be examined.
Integrate the general reductions in
expenditures in the social security tax
schedule
This will show the net rates of the
employer contribution, i.e., actually
provided by companies, instead of the
current higher gross figure, without
taking into account various tax reliefs.
The disconnection of the allocation of
receipts for financing general relief on
expenditures based on salaries from the
growth in their cost, since 2011, favours
integration.
Redefine and simplify ITAF for social
security
A refocus of fiscal financing of the
social security system around a smaller
number of taxes could be carried out to
increase transparency, with a growth in
receipts that is at least equivalent to that
obtained so far by all taxes within ITAF
whilst maintaining a diversification of
the bases in relation to being based on
work.
This reduction in the number of
taxes would go hand in hand with the
restructuring of the ITAF around a
main reference tax. Several options can
be considered:
- an accrued sharing of the VAT
revenue between the state and social
security;
- reinforcing the environmental
taxing set aside for social security;
- bringing ITAF and CSG closer
together.
It would be suitable to re-examine
the interest in continuing to ringfence
taxes that have a basis that places the
interests of social security against public
health
policies
(consumption
of
tobacco and alcohol).
Organise a general discussion focusing on
receipts from the financing law and the law
for financing social security
This reform would allow an overall
and more coherent approach to the
sources for financing the state and social
security. A single general discussion
would be followed by an examination of
the respective sections of the two texts
relating to revenues, before passing on
to an examination of expenditures.
Financing of
social security from taxes
28
Summary
of 2012 social security report
Recommendations
14
.
Examine the degree of
taxation sought for each social security
division (orientation).
15
.
Integrate general tax reliefs
within the tables for employer social
security contributions.
16
.
Redefine and simplify the
tax contributions earmarked for social
security as part of a consolidation of
this third funding pillar.
17
.
Organise
a
joint
examination of the revenues section of
the draft law for finance (PLF) and for
the draft social security financing law
(PLFSS).
29
Summary
of 2012 social security report
Cour des Comptes
6
Reform of the SNCF and
RATP pension schemes
Heavily subsidised
schemes that remain far
removed from the reforms
of 1993 and 2003
Pension reforms carried out in 1993
for the general scheme then in 2003 for
the civil service did not affect the
pension scheme for the French national
railway corporation (
Société Nationale des
Chemins de fer français
, SNCF) (162,300
contributors)
or
the
autonomous
operator of Paris transport systems
(
Régie Autonome des Transports
Parisiens
,
RATP) (43,600 contributors). However,
faced with large demographic and
financial
challenges,
these
special
schemes are mainly based on national
solidarity through large subsidies from
the State (in 2012, €3.2 billion for the
SNCF and €0.55 billion for the RATP).
Rather than an alignment with the
general scheme for private sector
employees, the public authorities have
finally opted, in 2007, for a progressive
convergence with the civil service
pension scheme. The principles and the
rules of the 2010 reform have been
applied to both schemes, but not the
December 2011 reform of the civil
service.
A partial and progressive
harmonisation with the
civil service
The convergence process involves
three major points:
1) The rules for allocating pensions.
The total duration of services and
service
improvements
giving
entitlement to a full-rate pension has
been harmonised with the civil service
by being platformed to 166 quarters.
The principle of automatic retirement at
the point of qualifying for retirement
has been abolished. The regulations for
duration of service and age for
qualifying for pensions have been
progressively extended (in 2022, age 52
for train crews or those working on the
RATP underground and the SNCF
drivers; age 57 for other SNCF staff and
RATP staff working in workshops; and
age 62 for RATP desk staff).
2) A re-evaluation of contribution
rates.
3) Indexing of pensions is no longer
based on company salary but on the
French consumer price index (excluding
tobacco), like other pension schemes.
The new reforms are however being
implemented progressively and with a
large
time-lag
(5-7
years)
when
Reform of the SNCF and RATP
pension schemes
30
Summary
of 2012 social security report
compared to changes made to the
pension scheme of the civil service.
Expensive considerations
for companies
The desire of the public authorities
to carry out the reform translated into
numerous “additional measures” for
employees, especially the SNCF.
Certain measures have been similar
in the two companies in the form of
additional
grades,
end
of
career
measures and integrating bonuses into
the pension.
Beyond this, companies have not
adopted the same strategy: in the RATP,
the measures have aimed to compensate
for the reform’s effects on the pension
levels (with full compensation for the
mid-2008 to mid-2012 period) whilst in
the SNCF, there has been a larger range
of measures (around twenty in total):
keeping senior staff within the company
has been encouraged by salary increases,
certain measures (“hard work bonuses”)
have benefited many railroad workers.
The staff have, as such, benefited
from significant advantages. For many
of them this constitutes a real “bonus
effect” that the workers did not feel
during the pension scheme reform of
2003.
Even more than for the companies,
the majority of these considerations will
affect the two retirement funds since
they will generate larger pensions.
Behavioural changes have been
observed in the SNCF since 2009:
employees retiring have pushed back
their retirement by 0.3 year each year
and the number of railroad workers
retiring at “minimum retirement age”
has fallen drastically.
Results that are largely
symbolic
Forecast gains that are limited
in the long-term
Depending
on
the
agreed
compensation measures, available data
and retained assumptions on departing
staff, the global balance sheet should be
negative for this decade and probably
slightly positive for the next twenty
years.
For the years 2011-2020,
the
accumulated
gain
for
the
SNCF
retirement fund will be equivalent to
€4.1 billion (in 2010 euros), and on the
order of €10.5 billion (2010 euros) for
the next twenty years. For the RATP
fund, this gain will be equivalent to
€0.27 billion (2010 euros) between
2011-2020 and €1.4 billion (2010 euros)
for the next twenty years.
These reforms however imply an
additional cost for both entities. For the
SNCF it will probably exceed the
equivalent of €4.7 billion (2010 euros)
for the present decade and €4.1 billion
(2010 euros) for the following decade.
For the RATP, the total cost of the
reform shall be €0.2 billion for
Reform of the SNCF and RATP
pension schemes
31
Summary
of 2012 social security report
2011-2020 and €0.6 billion for the
following decade.
Benefits are insufficient to significantly
lighten the state’s contribution
The symbolic element of these
reforms has been given priority over
their contribution to balancing public
finances. The state’s subsidising of these
schemes shall remain high in the long-
term: for the SNCF fund, while
diminishing from 2016, it will be
equivalent to around €2.2 billion
(2010 euros) in 2030, and for the RATP
fund it will continue to grow until 2019
and will be equivalent to €630 billion
(2010 euros) in 2030.
A stability that cannot be guaranteed in the
long term
In the medium term new steps will
be required to ensure the sustainability
of these two schemes.
The responsibility of these reforms
belongs as much to businesses as to
public authorities, who should assume
their task of generally steering these
schemes in a manner that is much more
coherent with the overall effort that will
be required to guarantee the long term
stability of the pension system as a
whole and taking into account the aim
of greater equality.
Recommendations
18. Supply the parliament with
detailed and up to date annual
information
regarding
the
implementation of reforms to the
SNCF and RATP schemes particularly
including information about changes
in retirement behaviour of staff as well
as an estimation of the provisional
balance of the schemes in the medium
and long terms according to various
assumptions.
19. Impose greater transparency
on the SNCF and RATP by laying out
plans for them to supply, in an annex
to their annual balance sheets, a
provisional
assessment,
following
rigorous methodological criteria, of
salary costs generated by the age
pyramid
and
specific
additional
measures associated with reforms in
the pension schemes of their staff.
33
Summary
of 2012 social security report
Cour des Comptes
7
The social security scheme
for self-employed workers
and the system for
collecting their
contributions
The social security scheme for self-
employed workers (RSI) covered close
to 2.7 million contributors in 2011,
2 million pensioners and 3.9 million
people benefiting from healthcare
insurance
services
and
receives
€8.2 billion in contributions.
The creation of this scheme in 2005
aimed to simplify the management of
social
protection
for
artisans,
tradespeople
and
self-employed
professions and gain efficiency in the
process, particularly with the transfer, in
2008, of the recovery of contributions
to the organisation for recovering social
security
contributions
(
Union
de
Recouvrement des Cotisations de Sécurité
Sociale et d’Allocations Familiales
, URSSAF)
and with the establishment of a single
system
for
self-employed
workers
(
interlocuteur social unique
, ISU).
A total failure
Serious difficulties for those people covered
The installation of this system at the
start of 2008 immediately caused major
difficulties for those covered. For a large
number of them, the creation of the
ISU
didn’t
just
mean
numerous
administrative difficulties, there was also
a risk of them losing their rights. So the
issuing of contributions was impacted
by many errors and a part of the money
collected was not able to be accounted
for correctly, which lead to many
contributors being subjected to the
automatic taxation scheme. Those
covered were not able to receive
reimbursement for their healthcare
because they didn’t have the required
health card, sometimes for very long
periods of time.
Significant financial consequences, mainly
eluded
Due to the long-term softening of
the
function
of
recovering
contributions, the Cour des Comptes
estimates a loss of income over the first
three years after establishing the ISU of
between €1-1.5 billion at the end of
2010.
The financial effects of these
malfunctions were hidden by the
automatic balance of the RSI with the
companies’ social security solidarity
contribution (C3S), which lead to the
social security debt being bloated
because of the resulting deficit accrued
from the old-age solidarity fund.
The social security scheme for self-
employed workers and the system
for collecting their contributions
34
Summary
of 2012 social security report
Difficulties that have
continued despite
successive plans
Originally, concerns about the
institutional balance were given priority
over the realism required for the correct
establishment of a new social security
scheme. The transfer of the recovery
was decided in the absence of a
common vision of the funds concerned,
and in a context of distrust between the
actors of the social protection of self-
employed individuals.
Furthermore, the complex nature of
the dialogue between the different
information systems has been largely
hidden at the time of arbitration, and
has not been considered as a risk factor.
Despite the commitment of RSI
and ACOSS staff the problems dragged
on for a long time because responses
were too slow and gradual to deal with
the design problems in the IT system.
The lasting illusion that actors have the
capacity to reduce the stocks of files
accumulated and the delay in organising
structured joint work just between the
two bodies since 2010 have resulted in
problems persisting.
Urgency in re-establishing
the system for recovering
contributions
Despite receipts partially catching
up since 2011, the recovery function is
yet to return to the position it was in
before the establishment of the ISU.
The amicable and forced recovery
procedures are still not fully restored.
The agreement on the objective and
management of the RSI from February
2012 doesn’t envisage collection until
mid-2014.
This re-establishment should be
placed at the top of the list of priorities,
especially for a scheme in structural
deficit that depends on the related tax
(C3S) for it to be balanced.
Since January 2001, the RSI and
ACOSS have been simultaneously
undertaking a particularly complex total
restructuring of their IT systems.
Taking into consideration the size of
the
challenge
and
the
significant
possible impact on all of the collections
performed by the URSSAF of a badly
designed information system, it is
imperative to perform a large and
precise audit of the relevant solutions
implemented and their capacity to build
an interface with the RSI.
Without solid assurances, the
question should be asked, once more,
about the creation of a social security
institution that is truly unique and
situated within a single organisation,
as opposed to the current ISU that is
shared between the ACCOSS and
the RSI.
The social security scheme for self-
employed workers and the system
for collecting their contributions
35
Summary
of 2012 social security report
Recommendations
20. Prior to any reform of such
a scale that is so complex, define a
rigorous system for managing the
project, particularly performing an
exhaustive analysis of risks prior to
any
definitive
decision,
using
a
framework of monitoring and steering
tools that match up to the challenge.
21.
Ensure
that
the
contributions not recovered are the
subject of all due diligence to
guarantee they are correctly identified
and not simply cancel or disregard
them, specify the scale of the delay in
recovery and implement a strict
monitoring system to reabsorb them in
order to minimise losses.
22. Reinforce the strategic
monitoring
of
tasks
currently
underway by the governing authorities,
providing explanatory information,
that is a broad as possible, including
financial information, and considers
the coordinated operational steering of
the RSI and ACOSS on a national and
regional level.
23. In order to guarantee a fast
and complete recovery within the
shortened deadlines, which is as robust
as possible, perform a complete in
depth audit of the future shared
information system, allowing:
- the pertinence of the project to
be ensured;
- the evaluation of risks of
postponing the scheduled date from
mid 2014, or failing to meet it, and
consider all possible consequences;
- examine, precisely, all of the
possible alternatives, including a study
of a simplification of the regulatory
framework of the ISU, or the re-
examination
of
the
shared
responsibility currently in vigour.
24. Guarantee that the rights
acquired by those covered in the name
of contributions made are taken into
account, exhaustively and swiftly,
within the RSI information systems.
37
Summary
of 2012 social security report
Cour des Comptes
8
The establishment
of ARS
A major structural reform
By setting up regional health boards
(
Agences Régionales de Santé
, ARS) and
assigning them regional management of
the health care system in a broad-based
approach encompassing prevention, the
organisation of private-practice and
hospital health care and the medico-
social sector, the Act of 21 July 2009
innovated in three key areas: roles and
responsibilities; regional administrative
organisation; and the conduct of public
policy.
The
26
ARS
simplified
the
institutional landscape by combining a
number of decentralised State services,
health insurance services, and bodies
such as the regional hospitalisation
boards
(
Agences
Régionale
de
l’Hospitalisation
, ARH) and the regional
public
health
groups
(
Groupements
Régionaux de Santé Publique
, GRSP),
which already combined the State and
health insurance services.
Rapid installation and
controlled costs
Property considerations were an
immediate concern for the directors,
right from the preliminary planning
phase, six months before the ARS were
actually installed on 1 April 2010. It was
decided, wherever possible, to have all
of the staff work at a single site and to
remain in the existing premises. The
great majority of new premises were
established in rented properties, which
will have a financial impact for the ARS.
Steps have been taken to reduce the
floor
space
occupied,
but
these
measures will have to be continued in
coming years.
A special budget of €58 million was
set aside for setting up the ARS. Known
as an initial installation budget, it was
financed by the health insurance system,
the State and the residual ARH working
capital fund. The total cost of setting up
the ARS is estimated at €70 million.
This includes the transfer allowances
granted to the staff of the health
insurance system and the cost of
management
within
the
ministry’s
general secretariat.
The institutional position
requires clarification
The goal is now for the ARS to
achieve the objectives set for them and
demonstrate their legitimacy with regard
The establishment of ARS
38
Summary
of 2012 social security report
to
the
other
national
and
local
stakeholders. They face a number of
difficulties in this respect.
National management remains very
hierarchical
The national management council
(
Conseil National de Pilotage
, CNP) set up
to coordinate the network of ARS and
ensure consistency in the national
policies they have to apply has failed so
far to initiate a national cross-cutting,
strategic approach to health and health
care issues.
Each central administrative body,
such as the national health insurance
fund
for
salaried
workers
(
Caisse
Nationale de l’Assurance Maladie des
Travailleurs
Salariés
,
CNAMTS),
continues to deal directly with the ARS
or the organisations in their network, in
a rather centralizing approach with no
lateral interaction.
Uneasy collaboration with the health
insurance system
Collaboration between the ARS and
the health insurance system, which is
necessary for taking risk management
measures, was long marked by a degree
of resistance on the part of the
CNAMTS as it strived to maintain some
of its prerogatives. It should improve
now that the ARS have been authorised
to use the health insurance system’s legal
tools and information systems.
Complicated relations with the prefects
Relations between the ARS, which
have taken over some of the areas of
responsibility formerly handled by the
decentralised State services (the regional
health and welfare department [
Direction
régionale des affaires sanitaires et sociales
,
DRASS] and the departmental health
and
welfare
department
[
Direction
départementale des affaires sanitaires et
sociales
, DDASS]), and the prefects
continue to be complicated. The latter
have kept their royal powers in matters
concerning public health monitoring,
safety and health regulations; the ARS
services are at their disposal to help
carry out these roles and responsibilities.
This new distribution of roles in the
wake of the State’s reorganisation at
regional level created tension. The
agreements signed between the ARS
and the departmental prefects to define
how their cooperation will work in
practice, and the joint instructions
issued by the general secretaries of the
French ministry of the interior and the
ministry in charge of welfare should
facilitate the partnership.
Operating resources need
to be modernised
If the ARS are to successfully fulfil
their roles and responsibilities, they
must also be able to take several other
measures.
The establishment of ARS
39
Summary
of 2012 social security report
Simplify workforce management and adjust
skills
The ARS face difficulties resulting
from the diverse statuses of their staff,
which are a carry-over from the
structures that merged to form the ARS,
and the mismatch between staff profiles
and their tasks. The juxtaposition of
private-sector statuses, for staff from
the health insurance system, and public-
sector statuses, for officers from State
services, results in disparate working
conditions and compensation. The role
of the joint administrative committees
in managing civil servants also limits the
powers of the director general of the
ARS. Lastly, the multitude of statuses
makes the system difficult to manage.
Invest in information systems
The ARS inherited an abundance of
information systems from the previous
organisations, and the systems are not
compatible. But if the ARS are to
successfully carry out their tasks, it is
absolutely essential to upgrade these
systems. A national master plan was
drawn up in 2011 to specify which ARS
projects should take priority and what
sort of governance should be set up in
terms of national management of the
information systems. It will only be
implemented, though, if the necessary
budgets are allocated to this priority.
Give the ARS the financial resources they
need to do the job
Work is still under way on giving the
ARS the resources they need to conduct
a regional health policy. The regional
operations fund (
Fonds d’intervention
régional
, FIR) established by the French
social security finance act (
Loi de
financement de la sécurité sociale
, LFSS) for
2012 - and which sets out to remove the
barriers between funding for private-
practice health care, hospitals and
medico-social facilities - is designed to
give the ARS greater leeway for
allocating certain finances. The reach
and effectiveness of this new tool will
depend on how it is implemented.
The establishment of ARS
40
Summary
of 2012 social security report
Recommendations
25. Set up a national manage-
ment system that allows ARS the
autonomy they need to carry out their
tasks. This implies:
-
defining
a
decentralisation
procedure
whereby
central
administrative bodies give the ARS
greater responsibility;
- restoring the CNP’s strategic
orientation function.
26.
Draw
up
the
next
agreements on targets and resources
(contrats d’objectifs et de moyens,
CPOM)
with
each
ARS.
The
agreements should:
- show how these targets fit in with
the regional health project’s targets;
- set targets for internal efficiency
or productivity gains that will keep the
ARS on track for the multi-year budget
road map.
27.
Simplify
ARS
human
resources management by:
- allowing them to recruit more
contract staff;
- bringing the situation of private-
law officers into line with the general
scheme’s
collective
bargaining
agreements (drawn up with the French
federation of national social security
funds:
Union des caisses nationales de
sécurité sociale
, UCANSS);
- laying down procedures for
transferring civil servants within the
same ARS.
28.
Implement
the
ARS
information system master plan and
make it a priority within the ministry.
29. Increase the FIR in order to
give the ARS greater leeway to take
financial measures.
41
Summary
of 2012 social security report
Cour des Comptes
9
The role of the Ordre
National des Médecins in
organising health care
and upholding medical
ethics
Oversight of the
profession is adequate on
the whole
One important role of the French
national board of medical doctors
(
Ordre National des Médecins
, ONM) is to
maintain an up-to-date list of medical
doctors fulfilling the required legal and
ethical conditions to practise. This role
enables
the
ONM
to
regulate
professional practice and publish an
annual study of medical demographics.
Legal changes such as the European
principle of automatically recognising
medical
degrees
and
registering
qualifications
have
broadened
the
ONM’s sphere of responsibility. The
ONM plays an active role in recognising
qualifications and assessing the validity
of the documentary proofs submitted
for the purpose.
The ONM was slow to become
involved, but now maintains a list of all
civil doctors in the shared register of
health care professionals that was
established. The register has simplified
the
formalities
for
doctors
and
improved communication between the
stakeholders (the ONM, the ARS and
the health insurance system). The ONM
has become their sole identification
authority.
A smaller contribution
now to round-the-clock
health care services
Round-the-clock
health
care
services organise a system of on-call
practitioners to meet unscheduled
demand for health care at night and on
weekends and public holidays. Up until
2003, it relied on compulsory on-call
duties supervised by the ONM. Now
the ONM acts as a facilitator and expert,
certifying volunteers’ capacity to assume
on-call duties and drawing up a list of
exempted doctors and a list of doctors
who can assume on-call duties. The
Cour des Comptes has noted that the
degree of involvement of councils and
doctors varies with the department, and
that it is increasingly difficult to provide
round-the-clock health care in rural
areas.
The role of the Ordre National des
Médecins in organising health care and
upholding medical ethics
42
Summary
of 2012 social security report
Insufficient adjustment to
the regional
reorganisation of the
health care system
The ONM is organised into 127
national, regional and departmental
councils. In 2007, it was decided to
broaden the responsibilities of the
regional councils in view of the regional
reorganisation of the health care system
led by the ARS. However practical
application of the reform is still patchy.
Controls on the upholding
of medical ethics do not
go far enough
Ethics oversight underpins the
ONM’s very existence. Its application is
essential in the interest of not only the
profession but also patients.
Numerous difficulties with handling
complaints
Responsibility for enforcing the
code of ethics lies with the disciplinary
bodies of the ONM’s regional councils,
most of whose members are drawn
from the medical profession, then with
the ONM’s appeals board. Complaint
processing times are sometimes long,
even though the number of cases
registered is stable at around 1,300 a
year. The severity of the sanctions varies
by region. Very often, sanctions are
accompanied by a total or partial
reprieve. ARS almost never refer
complaints
to
the
social
security
divisions that judge fraud or misuse
cases brought against practitioners, and
the health insurance system seldom
does so (200 cases are registered each
year).
Ineffective controls of the use of tact and
restraint in setting fees
The principle of tact and restraint
refers to the way doctors go about
charging higher than standard fees, and
how these fee surcharges are adjusted to
each patient’s financial means. The
national
council
issues
periodical
reminders of this principle, but few
cases are ever referred to the ONM
(around 15 convictions for misuse and
fee surcharges a year) and the sanctions
are very modest (generally a reprimand
or a warning).
This passivity is not really offset by
the other three measures in use at the
same time: the possibility of direct
sanctions
applied
by
the
health
insurance funds, criminal proceedings,
and sanctions under Annex XXII of the
medical agreement, renewed in July
2011. Although the volume of fee
surcharges is steadily growing, few
sanctions are applied and they are
generally not very harsh. The fact that
there are a variety of procedures
available is by no means a guarantee of
effectiveness.
The role of the Ordre National des
Médecins in organising health care and
upholding medical ethics
43
Summary
of 2012 social security report
More should be done to prevent conflicts of
interest
The ONM takes an active role in
preventing conflicts of interest:
- by overseeing work contracts
signed by doctors on its register, and
which doctors are required to send to
the departmental council responsible
for them. It checks that each situation
complies with the code of ethics (the
duty of secrecy, in particular). It also
checks professional independence and
that there is no productivity clause in
the doctor’s compensation. The ONM
plans to step up national oversight of
this role shortly;
-
by
controlling
the
relations
between doctors and industry. There is a
blanket ban on medical professions
receiving direct or indirect advantages in
kind or in cash from the pharmaceutical
industry, except for research, evaluation
or hospitality agreements. The ONM
issues
opinions
on
some
80,000
agreements
each
year,
but
the
conditions still vary with the department
and the ONM has undertaken to
harmonise them. Its powers were
reinforced by law in December 2011,
though not all of its proposals were
adopted by the legislator.
The scant cooperation between the
ONM and the French directorate for
competition, consumer rights, and
protection
against
fraud
(
Direction
Générale
de
la
Concurrence,
de
la
Consommation et de la Répression des Fraudes
,
DGCRF)
limits
their
respective
efficiency and calls for the conclusion
and application of measures to ensure
stricter enforcement of the so-called
“no-gifts” law. The State should also
stipulate
that
any
ONM
opinion
recommending against an agreement be
considered obligatory.
The role of the Ordre National des
Médecins in organising health care and
upholding medical ethics
44
Summary
of 2012 social security report
Recommendations
30.
Modernise the ONM’s
regional organisation and adapt it to
regional management of the health
care system by gradually transferring
the roles and responsibilities fulfilled
up until now at departmental level to
the regional councils.
31. Clarify and more effectively
coordinate the various measures used
to check the use of tact and restraint in
setting fees.
32. Give the ONM’s council
greater powers to control doctors’
relations with industry by making the
council’s opinion on a contract or
agreement - whatever its purpose -
obligatory. In the event of a negative
opinion, the contract or agreement
may not be carried out, on pain of
sanction.
33. Establish a protocol for
exchanging information between the
ONM and the DGCCRF, for greater
transparency and tighter control of
relations
between
doctors
and
industry, if necessary by using a
regulatory provision.
45
Summary
of 2012 social security report
Cour des Comptes
10
The health insurance
system’s payment of
social security
contributions for self-
employed health care
professionals
A cost of €2.2 billion for
the health insurance
system in 2011
For many years, this measure was
confined
to
sickness
insurance
contributions for Sector 1 doctors (i.e.
doctors who charge the standard fee set
by
the
social
security).
It
was
subsequently extended to include other
social security contributions and other
self-employed health care professionals
(dental
surgeons,
midwives
and
paramedics).
This payment on behalf of the
health care professionals contributes
substantially to their income: for Sector
1 doctors, it represented 18% of general
practitioners’ income in 2008 and nearly
16% of specialists’ income.
The payment covers practically the
entire health insurance contribution and
a large proportion of the personal
contribution for family allowances and
additional old-age coverage.
Over
the
years,
the
list
of
contributions paid and professionals
concerned has grown longer with each
round of talks between the health
insurance system and representatives of
the different professions.
Since 2004, nothing stands in the
way of the health insurance system also
paying the contributions of Sector 2
doctors (who set their own fees), even
though these doctors are free to choose
a
significantly
more
advantageous
affiliation, in terms of contributions, to
the social security scheme for self-
employed professionals (
Régime social des
indépendants
, RSI).
Despite their high cost for the health
insurance system, these measures are not
very visible and their purpose is not very
clear for either the beneficiaries or the
insured.
A system with no real
benefit in return
Initially, the aim of the system was
to encourage doctors to enter into a
contractual relationship with the health
insurance system so that it could impose
certain limits on their freedom to set
their own fees.
As it happens, though, this social
advantage plays only a very marginal
role:
The health insurance system’s payment of
social security contributions for self-
employed health care professionals
46
Summary
of 2012 social security report
- in the decision of an over-
whelming majority of doctors to sign an
agreement with the system, which is
mainly motivated by the desire to see
patients financially able to consult a
doctor because the health insurance
system reimburses their expenses;
- in doctors’ choice between Sector
1 and Sector 2.
The financial benefit that Sector 2
practitioners derive from being able to
charge higher fees far outweighs the
outlay generated by having to pay their
own contributions. When the health
insurance system assumes the cost of
medical practitioners’ contributions, this
is not used to promote a policy of
curbing fee surcharges, which are
applied more and more frequently by
these professions on a growing number
of medical procedures. The health
insurance system has had no influence
whatsoever on the dramatic increase in
fee surcharges observed in recent years
among doctors and dental surgeons.
Refocus the system on the
objectives of easy, fair
access to health care
A tool for distributing health care
professionals
An adjustment to all of the social
security advantages enjoyed by doctors,
including those already established,
based on whether they practise in areas
with a high or a low proportion of
doctors, could be applied to all of the
professions where the geographical
imbalances are such that they impede
equal access to health care. The health
insurance system’s financial contribution
would once more have a reason to be
clearly identified and recognised for both
professionals and the insured.
A possible contribution to regulating fee
surcharges
The
health
insurance
system’s
financial
contribution
appears
unjustified when, in practice, health
professionals
enjoy
considerable
freedom when it comes to their fees,
mainly through fee surcharges.
The conventional social security
advantages could be reserved for
categories of procedures to which social
security fees can really be applied. The
government should rapidly carry out a
stringent cost-benefit analysis of the
recent reform of the coordination
option, which establishes the extension
of
the
health
insurance
system’s
payment of contributions to Sector 2
practitioners.
Unless such advances can be
achieved, the question will have to be
raised of whether these advantages,
which bring nothing in return, should be
maintained.
At the very least, an effort should be
made to lower their cost. It would be
logical
to
cap
the
benefit
per
professional. This could be done by
capping the basis used for calculating
the benefit, and/or applying some form
of sliding scale (as is already the case for
family contributions).
The health insurance system’s payment of
social security contributions for self-
employed health care professionals
47
Summary
of 2012 social security report
Recommendations
34. Reform the system in order
to facilitate access to health care:
-
by adjusting the amount of
contributions paid on professionals’
behalf according to the density of
health care professionals in a given
area;
-
by excluding income derived
from categories of procedures where
fee
surcharges
are
almost
systematically charged;
-
or by making them subject to
compliance with surcharge ceilings.
Failing
this,
stop
paying
contributions on practitioners’ behalf
or, at the very least, cap the amount
per health care professional.
35. Make it mandatory for all
contracted health care professionals to
be affiliated with the scheme for
contracted
practitioners
and
paramedics (
praticiens et auxiliaires
médicaux conventionnés
, PAMC). This
means
that,
unlike
Sector
2
practitioners, they would no longer to
be free to join the RSI scheme.
36. Make these payments more
visible, like the employer contributions
shown on pay slips, by showing their
cost in an annual statement sent to
professionals by the health insurance
system.
37. Regarding the rules specific
to the PAMC scheme:
-
bring them into line with the
rules that apply to other social security
contributions as concerns the period
of insurance cover and the basis used
for calculation;
-
remove the ceiling from this
basis in the case of income derived
from non-reimbursable procedures;
-
make it compulsory to show
all of the procedures performed and
the professional fees received on the
medical claim form.
49
Summary
of 2012 social security report
Cour des Comptes
11
Patient transport costs
paid by the health
insurance system
A dynamic expenditure of
€3.5 billion a year
Depending on patients’ state of
health, they can be transported by
ambulance or by professional seated
patient
transport
(
transports
assis
professionnalisés
, TAP), i.e. in a taxi that
has signed an agreement with the health
insurance system or in a patient
transport car (
véhicule sanitaire léger
, VSL).
The health insurance system pays the
cost of patient transport, in full or
partially. In 2010, these costs amounted
to a total of €3.5 billion. They are
increasing steeply and at a faster pace
than the other health care costs. They
now
represent
50%
of
the
reimbursements of general practitioner
consultations. A sizeable proportion of
them could be avoided, though, without
deteriorating access to health care.
Poorly documented growth
factors
Transport usage has a number of
causes: the population’s state of health,
the organisation of health care services,
doctors’ attitudes to prescribing patient
transport, and the range of available
transport services. No in-depth study
has been carried out to understand how
these factors are linked, or local
differences, even though this is a vital
step
towards
controlling
this
expenditure.
Tighten controls on
transport prescriptions
An initiative to curb prescriptions partially
implemented
Formal
prescription
guidelines
define the conditions requiring patient
transport. However insufficient steps
are
taken
to
ensure
compliance,
particularly regarding the need for
ambulance transport, which is more
expensive, or documentary evidence
that the transport is linked to a long-
term condition, in which case the
transport costs are fully reimbursed. A
more stringent application of the
guidelines would limit the amount of
unjustified
expenses,
which
are
estimated
at
nearly
€220
million
nationally.
Moreover, the rule stating that
transport costs are reimbursed on the
basis of the distance from the patient’s
pick-up point to the nearest suitable
facility - aimed at keeping transport to a
minimum, based on the range of
Patient transport costs paid by the
health insurance system
50
Summary
of 2012 social security report
available health care facilities - is not
strictly applied.
Prescribers not very aware of their
responsibilities
The bulk of efforts to control the
demand for patient transport has
focused on private-practice doctors. The
heaviest prescribers of transport have
been obliged to seek prior approval,
under a procedure introduced by the
French Health Insurance Act of 2004.
However this measure concerned only a
small number of prescribers (a total of
76 in 2008) and applies only to doctors
in private practice.
But it is the doctors in health care
facilities who prescribe the most
transport (53% of expenditure) and no
real measure was taken to ensure tighter
control of transport prescribed in
hospital until 2010. The budget act for
2010 provided for contracts to be drawn
up between the ARS, the local health
insurance bodies and the hospitals,
whose
transport
expenses
have
increased sharply, but the tools that
would allow these contracts to be
implemented have not been brought in.
Apply tighter quota
restrictions on the supply
of transport
Quota restrictions on the supply
side are the most effective means of
controlling this expenditure, but the
measures introduced are ineffective.
The Cour des Comptes has noted
that there are considerably more
ambulances and patient transport cars
than necessary: in over two-thirds of
French departments, the number of
vehicles exceeds the ceiling set by a 1995
regulation.
Moreover,
the
quota
restrictions can be by-passed by using
contracted taxis.
The organisation and fee structure
of the on-call ambulance system - which
responds
to
requests
from
the
emergency medical services (
Service
d’Aide Médicale Urgente
, SAMU) on
Saturdays, Sundays and week nights -
has two major flaws. There is no
financial incentive for the transport
company to respond to the SAMU’s
requests, and in some sectors, the
number of patients transported during
the on-call period does not warrant
having
two
on-call
systems,
one
provided
by
patient-transport
companies and the other by the
departmental
fire
and
emergency
response service (
Service départemental
d’incendie et de secours
, SDIS). Reforming
this on-call system could save nearly
€100 million a year.
Fix up management
shortcomings
At the moment, the health insurance
system has little interaction with taxis
and no reliable statistics on the sector.
Additionally, there is no common
pricing system between VSL and taxis
for the same service, even though
patient transport companies often have
taxis as well as VSL.
Patient transport costs paid by the
health insurance system
51
Summary
of 2012 social security report
Enforce the prescription guidelines
220
Reform on-call ambulance services
100
Assess invoiced amounts more accurately
120
Total
440
Lastly, local management is poorly
distributed between the ARS and the
primary health insurance funds (
Caisses
primaires d’assurance maladie
, CPAM). The
director general of the ARS accredits
the patient transport companies and
grants authorisations to commission
vehicles (ambulances and VSL). Each
patient transport company signs the
national agreement established between
the health insurance system and the
professional bodies, through the CPAM.
The ARS have not compiled a national
register of accreditations and patient
transport vehicles, and they do not have
access to the register compiled by the
health insurance system.
Run more stringent
invoice checks and audits
Patient transport companies and
taxis offer the possibility of using the
third-party payer system, and send their
invoices directly to the local health
insurance funds. However the funds
very seldom check for the supporting
documents and essential verifications
are not carried out, with the result that
the health insurance system sometimes
makes overpayments.
An amount of €120 million could
be saved by running tighter checks on
how the invoices - and especially the
mileage figures - are calculated.
The anti-fraud plans drawn up at
national level and applied by the CPAM
are far from yielding an accurate
assessment of the level of fraud. The
national review shows that a large part
of the audits result in recovering
overpayments, without any penalties
being applied. For the companies
concerned, therefore, the audits are not
dissuasive at all.
In all, at least €450 million of the
€3.5 billion paid out in refunds could be
saved without deteriorating access to
health care.
Main ways to save money without deteriorating access to health care
(
€m)
Source: Cour des Comptes calculations based on data from the CNAMTS and the Directorate
General of Care Provision (
Direction générale de l’offre de soins
, DGOS)
Patient transport costs paid by the
health insurance system
52
Summary
of 2012 social security report
Recommendations
38. Analyse supply and demand
in patient transport services in order to
define a cost-cutting action plan with
specific target figures. This analysis
should be carried out without delay in
every
department,
under
the
responsibility of the ARS, using data
from the health insurance system.
39.
Step up coordination
between the ARS and the health
insurance
funds
for
accrediting,
signing
agreements
with
and
controlling
patient
transport
companies and taxis.
40.
Introduce
a
dual
departmental
ceiling
for
patient
transport services: one for ambulances
and the other for VSL and contracted
taxis.
41. Define a common, verifiable
pricing structure for VSL and taxis,
and
lower
the
percentage
of
overpayments by effectively checking
invoices.
42. Systematically apply anti-
fraud measures and revise the range of
penalties applied for improper or
fraudulent invoicing to make them
dissuasive.
43. Revise the conditions in
which applications for prior consent
are necessary, reactivate the rule of the
nearest health care facility, including
for
dialysis,
chemotherapy
and
radiotherapy, and have the health
insurance system’s medical service
check
compliance
with
the
prescription guidelines.
44. Consider transferring the
transport costs hospitals initiate to
their budget so that the prescription,
organisation and public-procurement
management of this expenditure is
subject to budget constraints.
45.
Carry out an in-depth
evaluation of the ambulance on-call
system with a view to reorganising its
organisation.
53
Summary
of 2012 social security report
Cour des Comptes
12
Aftercare and
rehabilitation
Every year, 900,000 patients enter
aftercare and rehabilitation units (
services
de soins de suite et de réadaptation
, SSR) for
rehabilitation or convalescent care. This
sector, which can cater for 106,000
patients and outpatients, lies at the
crossroads of general practice, short-
term hospitalisation, and welfare and
medico-welfare care. The ensuing health
insurance expenditure is expected to
amount to €7.8 billion in 2012.
A sector marked by
diversity
The very diverse nature of the
sector is mainly the result of the type of
care given. The 2008 reform that made
the sector more medical and technical
has not eliminated all of the overlapping
between specialisations, and patients -
especially elderly patients - are not
always referred to the most appropriate
specialist.
Depending on their status, SSR
facilities have different management
systems. Private facilities, whether they
are non-profit (
Etablissements de santé
privés d’intérêt collectif
, ESPIC) or for-
profit (clinics), represent just over half
of all facilities and 60% of the care
dispensed. They are more likely than
public facilities to be specialised in one
or two types of care, such as orthopedic
rehabilitation or respiratory disease.
Public facilities tend to be more general
in nature. The bulk of their activity
derives from prescriptions from short-
term hospitalisation units. It is difficult
to tell, though, what category of facility
cares for patients with more severe or
more complex disorders.
Public and non-profit facilities
financed by an overall allotment have an
average daily cost that is 40% higher
than clinics financed by a per-diem rate.
This latter pricing system tends to
encourage an increase in activity and
explains, in part, the higher occupancy
rate in clinics, even if other factors have
to be taken into account to explain these
lower costs, such as fewer medical staff,
less dependent patients, and, to some
extent at least, better organised facilities.
No real needs analysis
behind the supply side
In eight years, patient/outpatient
capacity has increased by 12.3%, with
the for-profit private sector proving the
most dynamic.
However there was no precise
management behind this expansion.
There was limited assessment of the
qualitative
and
quantitative
Aftercare and rehabilitation
54
Summary
of 2012 social security report
requirements. The assessment focused
mainly on regional differences, with no
national overview, and insufficient
attention was given to a pathology-
based approach. No provisions were
made
for
distributing
locally-
developped patient-referral aid tools
such as Trajectoire, for example,
nationwide.
The supervisory authority did not
realise how fast expenditure was
growing until 2010, long after the
applications for consent imposed on
health care facilities by the 2008 reform
had been processed.
As a result, there were no means for
enforcing regulation for a long time, and
even now regulation is not perfect. The
budget act for 2011 established a prior
consent
mechanism
for
some
procedures, but it has only limited scope
for the moment. The accompanying
creation of a specific sub-objective for
SSR activities, as part of the annual
projected health insurance expenditure
(ONDAM) should help more effectively
regulate
expenditure.
A
study
of
inappropriate
stays
in
short-term
hospitalisation units has begun to bring
the very necessity of creating SSR beds
under critical examination. But, for want
of a similar study on inappropriate stays
in SSR units, consideration of the issue
remains incomplete.
Give priority to
streamlining the health
care path
For the SSR activity to operate
efficiently, it is fundamentally important
for the health care and medico-welfare
sectors to be properly coordinated in
the patient’s health care path.
But patients continue to experience
obstructions, delays and inappropriate
referrals both when they enter and when
they leave SSR. Estimates put the
number of inappropriate admissions at
between 10% and 20% of SSR beds. On
top of the inappropriate admissions,
there is an increase in the number of
early admissions of non-stabilised
patients who in fact require continued
acute care. It is even more problematic
when patients leave the facilities,
especially when they cannot go home.
As a result, SSR activities are doubly
dependent: on upstream hospital care
and on downstream medico-welfare
care. This inevitably has an effect on the
problem of their financing.
Aftercare and rehabilitation
55
Summary
of 2012 social security report
A sector looking for
appropriate financing
Current financing arrangements
raise the problem of fairness, since the
differences in budget allotments or rates
between facilities bear no connection
with the complexity of the cases
handled.
However, for some years now there
have been plans for a rapid changeover
to an activity-based rate structure
revolving around a medium-term stay.
This
implies
the
existence
of
stakeholders
capable
of
making
independent decisions and equipped
with the means to manage their activity.
SSR, especially in the public sector, has
not attained this degree of maturity.
Quite apart from the technical
problems, much has yet to be done in
the way of design and testing in order to
develop an appropriate system of
financing. Before this can be achieved,
patients’ path between the various links
in the health care chain must be made
smoother and easier.
Aftercare and rehabilitation
56
Summary
of 2012 social security report
Recommendations
46. Evaluate the number of
inappropriate stays in SSR at national
level, using a consistent methodology.
Use the results to deduce the actual
requirements for SSR care, based on
the pathologies to be treated.
47. Based on these figures, set
precise objectives for the ARS in order
to solve the difficulties of referring
patients whose condition allows them
to leave SSR. Rapidly bring in tools
(e.g. Trajectoire) that will provide clear
operational data on the availability of
beds and places:
-
for patients transferring from
medicine-surgery-obstetrics (
Médecine-
Chirurgie-Obstétrique
, MCO) to SSR, on
the one hand;
-
for patients transferring from
SSR to downstream medico-welfare
services on the other.
48. Before starting to reform
the financing arrangements, carry out
tests to ensure that the reform will in
fact rationalise financing without
generating additional problems in
patients’ health care path.
In the
meantime, improve the operational
aspects of adjusting the annual
financing allotment (
Dotation annuelle de
financement
, DAF) and the per-diem
rate according to the complexity of
the treatments dispensed.
57
Summary
of 2012 social security report
Cour des Comptes
13
Certification of hospitals
by the French National
Authority for Health
The hospital certification procedure
is
aimed
at
contributing
to
the
continuous improvement of the quality
and safety of the health care delivered to
patients. Using indicators, criteria and
standard
reference
documents,
it
assesses the quality of a health care
facility or its services. The French
National Authority for Health (
Haute
autorité
de
santé
,
HAS)
has
been
responsible for this task since 2004. In
2010, the cost was estimated at
€22.4 million (excluding the cost for the
facilities).
Efforts to simplify and
medicalise the procedure
should be continued
The French procedure is loosely
based on examples in other countries. It
differs from them in that it is
compulsory, it is implemented by a
single national body, and its results have
no legal or financial consequences for
the facilities.
Since 1996, virtually all facilities
have
completed
two
certification
procedures and begun a third one.
The procedure has been gradually
medicalised, simplified and made more
understandable. For instance, improving
the medical service provided to patients
has been written into the objectives, and
indicators have been introduced to
measure health care quality. Two new
tools
would
further
simplify
the
procedure: risk mapping for each
facility, based on the results of earlier
certification cycles, and upgrading
hospital information systems so that
indicators were automatically filled in.
New room for
improvement
With successive procedures, we
observe a risk that certification will
become less effective. This should
prompt the HAS to improve its
approach.
Specify the scope of certification
Each facility is currently covered by
a single certification procedure, even if
its activity is carried out at more than
one site. As a result, sites of different
quality are regarded as one, and
differences
arise
in
certification
requirements depending on the size of
the facilities. In large groups, such as the
public hospital systems of the cities of
Paris
and
Marseille
(respectively
Assistance publique – Hôpitaux de Paris
,
AP-HP
and
Assistance
publique
–
Hôpitaux
de
Marseille
,
AP-HM),
Certification of hospitals by the
French National Authority for Health
58
Summary
of 2012 social security report
individual site inspections could be
organised in addition to inspections of
each legel entity.
Improve measurement of the impact of
certification
Alongside the third-party studies on
how certification affects the facilities
involved, the HAS could analyse the
data it has collected itself.
Detect risk areas
The HAS is not systematically
informed of the serious undesirable
events that occur in some units, even
though this could allow it to compare
the
problems
observed
with
the
certification reports, and learn lessons
for the future.
Emphasise the medical aspects of
certification
The quality approach introduced by
certification also involves periodically
evaluating the doctors and medical
teams - which is currently a blind spot in
the procedure - and certifying a given
facility by coherent groups of activities
deemed to be risky.
Inform the public of the outcome of
certification
The HAS website publishes all
certification reports, but it is difficult for
a non-specialist to interpret the mass of
data presented there.
The HAS should publish an annual
overall certification report by category
of facilities (public, for-profit and non-
profit private), showing the risk areas it
detected.
Take the certification results into account in
the facilities’ agreements on targets and
resources.
Currently there is no outside
incentive for facilities to progress
towards “full” certification, with no
reservations or recommendations.
There are a number of possible
avenues for reform:
- establish closer links between the
procedure in which facilities sign
contracts with the ARS and the
certification procedure by the HAS;
- write into the agreements on
targets and resources signed by the ARS
and the State targets corresponding to
the measures necessary for applying the
recommendations and removing the
reservations
expressed
during
the
certification procedure;
- or refuse to grant permission for
high-risk treatments if a facility is not
certified, or if the certification decision
has been suspended because of major
reservations.
Certification of hospitals by the
French National Authority for Health
59
Summary
of 2012 social security report
Recommendations
49. Carry out impact studies by
cycle, by category of facility and by
region, and use the lessons learnt to
improve the certification procedure
and build facilities’ knowledge.
50.
Accentuate
the
medicalisation of the approach by
systematically studying discrepancies
between the certification decisions and
serious undesirable events brought to
the knowledge of the HAS, by
developing
the
accreditation
of
doctors
and
medical
teams,
by
promoting staff training courses on
best practices, and by testing the
certification of coordinated groups of
activities.
51.
Include the certification
results in the contracts negotiated by
the ARS with the facilities in order to
monitor application of the HAS
recommendations,
remove
reservations, and derive financial
consequences if necessary.
61
Summary
of 2012 social security report
Cour des Comptes
14
Old-age coverage for
the poorest people
Nearly one million people over the
age of 64 were living below the poverty
line in 2009. This is over 10% of this
age bracket. The bulk of their resources
comes from the social protection
system: pension schemes and national
solidarity in the form of the basic old
age pension.
The basic old age pension
still plays a major role
The basic old age pension, which
was
created
in
1956,
covers
940,000 people, including beneficiaries’
spouses and beneficiaries living abroad
(close to 240,000 people). Over 55% of
the beneficiaries of the basic old age
pension are women. One quarter of
them are over the age of 80.
This benefit, now known as the
solidarity
benefit
for
the
elderly
(Allocation de solidarité aux personnes
âgées, ASPA), can be paid to anyone
aged 65 or over, providing the person
applies for it. It brings its beneficiaries’
total resources up to €777,16 a month
for a single person or €1,206.39 for a
couple.
Despite the end of the 60-year rise
of the basic and complementary
pension schemes, and the introduction
of minimum pensions by the main
retirement schemes, the basic old age
pension is still a key tool for keeping the
elderly out of poverty.
In 2011, the basic old age pension
represented a total expenditure of
€3 billion, financed by the old-age
solidarity fund (FSV).
The need for more active
measures to inform
potential beneficiaries
For the system to play its role more
effectively, more active measures have to
be taken, earlier, to inform eligible
people.
The
fact
that
the
2007-2012
revalorisation plan did not have any
significant effect on the number of
beneficiaries suggests that a large part of
the new potential beneficiaries did not
spontaneously apply for the benefit.
Part of this sector of the population
is still unknown and will remain
unknown
unless
the
management
bodies organise canvassing campaigns.
Expenditure could remain
dynamic
The basic old age pension was long
considered to be bound for gradual
extinction, but the decline in beneficiary
numbers came to a halt in 2007.
Old-age coverage for
the poorest people
62
Summary
of 2012 social security report
Two factors may even see its cost
increase. The first of these is the recent
drop in the average resources of new
beneficiaries prior to the benefit. (The
average value of the basic pensions
assessed in the general scheme for new
beneficiaries of the basic old age
pension who have not worked the full
number of years has gone from €314 a
month in 2006 to €294 a month in 2010
in 2006 constant euros.) The second
factor is that generations with more
discontinuous careers are reaching
retirement age.
Regulation mechanisms
have limited effectiveness
There are few tools available for
containing this mounting expenditure.
The new rules applicable since 2007 are
admittedly more restrictive, but they
apply only to new beneficiaries. In
addition, benefits paid outside France
before 2006 continue to be paid, though
the legal framework is ambiguous.
The possible adjustments have a
limited scope:
- removing the ceiling on the
recovery of benefits on an estate seems
justified, but would probably have only
very modest financial effects;
- better coordination with the age-
related measures in the pensions reform
could also be considered. This would
consist in pushing back the minimum
age for receiving the basic old age
pension, in the same way as for the full
old age pension.
Clear, sustainable
financing for the system
has become a necessity
Since the legislator chose to tighten
the requirements for granting the basic
old age pension only for newcomers, it
is essential to find a way to provide clear,
sustainable financing.
It is also important to give the FSV
lasting resources to cover the deficit,
which reached €3.45 billion in 2011 (the
ASPA is largely responsible for this
imbalance).
Without these resources, this
system of national solidarity will
continue to be financed by the social
security debt, i.e. by the generations to
come.
Old-age coverage for
the poorest people
63
Summary
of 2012 social security report
Recommendations
52.
Provide
clear,
stable
financing to cover the cost of the basic
old age pension by raising the
resources allocated to the FSV.
53. Clarify the legal grounds for
continuing to pay the L. 814-2 increase
abroad.
54. Harmonise the procedures
for controls and their monitoring
between the different bodies managing
the basic old age pension by aligning
them on best practices.
55. Remove the ceiling on the
value of the ASPA benefits that can be
recovered from an estate, and make it
routine practice to recover from an
estate the future payments of all level
one benefits.
56. Push back the common law
minimum age for receiving the ASPA
at the same rate as the age for
cancelling the discount in the general
scheme.
57.
Use suitable means of
informing the public:
- organise a meeting for 65-year-
olds
at
the
National
Old
Age
Insurance Fund (
Caisse nationale de
l’assurance vieillesse
, CNAV) and the
Central Agricultural Mutual Insurance
Fund (
Caisse Centrale de la Mutualité
Sociale Agricole
, CCMSA) to repeat
information about the ASPA given
when the pension was assessed, or step
up partnership initiatives between the
pension funds and local authorities’
welfare services;
- conduct an active canvassing
campaign addressed at retired people
who might have become eligible for
the basic old age pension following the
recent revalorisation plan.
65
Summary
of 2012 social security report
Cour des Comptes
15
Specific tax and welfare
measures for retired
people
Although there are still some
individual situations that are cause for
concern
(1
)
, the retired population is in a
generally more favourable financial
position
today
than
the
working
population. After having examined
some of the specific measures for
retired people, the Cour des Comptes
surveys possible options for greater
solidarity and greater equity between the
generations.
A cost of around
€12 billion
(2)
Substantial tax relief
Tax loopholes for income tax, which
do not concern low-income retired
people, provide growing support as the
income level rises, so mainly benefit
wealthy retired people.
The cost of the tax expenditure
examined with regard to income tax
comes to a total of around €4.5 billion
(in particular the 10% discount on
pensions even though retired people no
longer
have
to
pay
professional
expenses, and the exemption from
pension increases for children).
The tax relief on local taxes granted
to people over 60 cost €0.8 billion
(exemption from the residence tax, the
television licence fee and the tax on
developed land).
Costly welfare loopholes
Whereas the universal social security
tax (
contribution sociale généralisée
, CSG) is
calculated at 7.5% for all people in
employment,
regardless
of
their
remuneration, there are three different
rates for retired people, depending on
the value of their pension: 49% of
retired people pay 6.6% in CSG, 12%
pay 3.8% and 32% are exempted (2008
figures).
This
situation
leads
to
inconsistency and threshold effects, and
does not seem justified from an
economic or social point of view, at
least not for the highest pensions,
especially as this measure (the 6.6% rate
________
(1) See previous chapter on old-age coverage for the poorest people.
(2) The various retirement family benefits represent close to €15 billion. The latter include pension
increases for parents of three children or more. The Cour des Comptes has requested on several
occasions that they be taxed and/or capped.
Specific tax and welfare measures
for retired people
66
Summary
of 2012 social security report
rather than 7.5%) results in lost revenue
of nearly €1.2 billion.
The pensions paid by the basic
schemes have been exempted from
health insurance contributions since
1998.
A
1%
health
insurance
contribution
is
still
applied
on
complementary
or
supplemental
retirement benefits.
All employers over the age of 70,
whatever their income, are exempted
from paying employer contributions up
to a ceiling rate that can reach €245 a
month. These exemptions represent a
total cost of €0.4 billion.
Retired people generally
better off than the rest of
the population
Some pensioners, especially women,
have low incomes, as shown in the
previous chapter, and ageing gradually
confronts them with a risk of loss of
autonomy
that
incurs
substantial
expenses.
Even
so,
the
retired
population as a whole has caught up
with or even overtaken the income level
of the rest of the population.
This catch-up effect, which was
particularly noticeable up until the early
80s due to the ramp-up of the
retirement
schemes
and
a
high
revalorisation rate for pensions, is still
continuing today. The new generations
of retired people have accumulated
higher
pension
entitlements.
The
average
direct-entitlement
pension
(basic and complementary) reached
€1,350 in 2010 as against €1,029 in 2004,
which corresponds to an 8% increase in
purchasing power.
Retired people also have higher
average personal wealth than people in
employment. In 2004, the average
wealth of retired households was
€252,700, as against €213,600 for
working households.
Lastly, retired people have a higher
standard of living than the rest of the
population because they have financial
income and because elderly people are
more likely to be the owner-occupier of
their primary residence than people in
employment: this is the case for 72% of
over-60-year-olds, as against 58% on
average. According to the National
Institute of Statistics and Economic
Studies (
Institut national de la statistique et
des études économiques
, INSEE), retired
people’s average standard of living has
nosed ahead of that of working people
in recent years (respectively, €23,970 and
€23,060 in 2006).
Specific tax and welfare measures
for retired people
67
Summary
of 2012 social security report
The need for change
Less justification for tax relief and welfare
advantages
As some other categories of the
population,
and
especially
young
workers, see their conditions deteriorate,
it seems necessary to re-examine all of
the existing support mechanisms, which
still often date back to a time when the
situation of the elderly was particularly
precarious.
The issue is all the more pressing as
public finances are under mounting
pressure, additional demands have been
placed on people in employment, and
new needs are emerging: the cost of
dependency or the cost of helping
young people enter the workforce or
obtain housing.
Gradually harnessing the room for
manoeuvre
While being careful not to fragilise
the
most
modest
retired
people,
attention should be focused on four
measures:
- remove the 10% discount on
pensions for income tax (estimated
saving: €2.7 billion);
- bring the CSG rate on the highest
pensions into line with the rate applied
to wages and salaries (estimated saving:
€1.2 billion);
- remove the income tax exemption
applied to pension increases for children
(estimated saving: €0.8 billion);
- means-test the exemption from
employer contributions for elderly
individuals employing staff in the home.
Specific tax and welfare measures
for retired people
68
Summary
of 2012 social security report
Recommendations
58. As already recommended by
the Cour des Comptes, gradually phase
out the following tax expenditure and
welfare loopholes:
- the 10% discount applied to
pensions in the income tax declaration
(saving: €2.7 billion);
- the exemption from income tax
of the pension increases for parents of
three children (saving: €0.8 billion);
- non-alignment of the CSG rate
applied to the highest pensions (6.6%)
on the rate applied to wages and
salaries (7.5%) (saving: €1.2 billion).
59.
Means-test
the
total
exemption from employer contributions
granted to certain categories of private-
individual employers.
60. Extend the basis used to
calculate
health
insurance
contributions at the rate of 1% to
include all complementary retirement
pensions and basic pensions (above a
certain threshold) when the distinction
between these two types of pension
benefits is not relevant.
61. Examine the consequences
of eventually removing age-related tax
relief on local taxes.
69
Summary
of 2012 social security report
Cour des Comptes
16
The redistributive
function of means-tested
family benefits
The means-testing of certain family
benefits from the 1970s onwards gave
family policy a new purpose. Alongside
its traditional objective of off-setting
differences in standards of living
between families without children and
families with children, it was now to
help narrow income gaps among
families with children.
The growing importance
of benefits
Family benefits include the family
supplement (
complément familial
, CF), the
school benefit (
allocation de rentrée scolaire
,
ARS) and the various components of
the young child benefit (
prestation d’accueil
du jeune enfant
, PAJE): birth or adoption
bonus (
primes de naissance ou d’adoption
,
PN), basic benefit (
allocation de base
, AB)
and childcare supplement (
complément de
mode de garde
, CMG).
Unlike universal benefits such as the
family benefits, these benefits are
granted after means-testing or adjusted
to the family’s resources.
This particular dimension of family
policy, which is more specifically
concerned with its welfare objective,
accounted for 44% of the total volume
of family benefits in 2010, as against
29% in 2000, i.e. over €13 billion. This
growth stems mainly from the increase
in the CMG benefit, as the other
benefits tended to decline. The 25%
increase in the ARS adopted in the
summer of 2012, which should be off-
set by adjusting the family quotient for a
similar amount, represents additional
expenditure of €0.4 billion for the
division.
A lack of overall
consistency
Means-tested benefits address very
different
objectives:
the
expenses
incurred in caring for young children
(PN and AB components of the PAJE)
or schooling (ARS), support for large
families (CF), or help with reconciling
family life and work life (the CMG
component of the PAJE). As a result,
each type of benefit has specific, highly
changeable eligibility rules, and the
monetary value varies substantially from
one benefit to the next.
The ceilings applied to means-tested
benefits
reflect
a
more
or
less
accentuated targeting, with no overall
consistency, and which is accordingly
very disparate.
The CMG benefit is in a class of its
own because, although the amount
varies
according
to
the
family’s
The redistributive function of
means-tested family benefits
70
Summary
of 2012 social security report
resources, all families, whatever their
income level, can receive this benefit. It
amounts to €171 a month for one child,
whether the family has a monthly
income of €4,000 or €20,000.
Nor is the amount of the benefits
dictated by a consistent approach to the
cost of the child.
Little effect on income
levelling
An average 34% of the families
eligible for these benefits have incomes
that are too high for them to receive
them. This shows a generally moderate
selectiveness: very low for the AB
component of the PAJE, which is an
almost universal benefit, and much
higher for the ARS.
As
far
as
vertical
income
redistribution is concerned, the true
means-tested benefits (the AB and PN
components of the PAJE, the CF and
ARS benefits) have only limited effects
on families’ incomes and reducing the
poverty rate.
The CMG benefit, which varies with
the family’s resources, is mainly paid to
wealthy families.
A smaller role in income
levelling than the
universal benefits
Among the benefits associated with
young children, the non-means-tested
benefits have the most noticeable
income-levelling effects (60%), ahead of
the means-tested benefits (40%). This
situation can be attributed to the higher
volume of the former. Among these
benefits, the AB component of the
PAJE does the most to level incomes
since, even if it is not very progressive
by comparison with the CF or the ARS,
it represents a large financial sum. On
the other hand, it is the wealthier
families who benefit most from the
CMG, since there is no ceiling. The
volume of CMG benefits has increased
sharply in recent years and it now tops
€5 billion. Out of this total, families in
the ninth and tenth standard-of-living
deciles received €2.1 billion in CMG
benefits in 2009.
In all, the lower 50% of households
- which represent only 30% of income -
account for 75% of means-tested
benefits and receive only 20% of the
benefits that vary with the family
resources.
The redistributive function of means-
tested family benefits
71
Summary
of 2012 social security report
Revise the overall
economy of means-tested
benefits
Lowering the resource ceiling for
the AB, which is particularly high, and
introducing a resource ceiling for the
upper bracket of the CMG would free
up considerable financing capacity that
could be redeployed to benefit the most
modest families without adversely
affecting the need to make up the deficit
in the Family Division.
Recommendation
62. Revise the overall economy
of family benefits that are either
means-tested or adjusted according to
resources:
-
give greater priority to the
objective of supporting vulnerable
families;
-
reform the AB and CMG
components of the PAJE benefit to
target a narrower group of beneficiary
families, and apply a resource ceiling
for receiving the CMG benefit.
73
Summary
of 2012 social security report
Cour des Comptes
17
Direction and
management of the
information system of
the general scheme’s
Family Division
The next 2013-2016 objectives and
management
agreement
(
convention
d’objectif et de gestion
, COG) between the
State and the national fund must be
used to completely redefine the strategic
objectives and the procedures for
directing and managing the division’s IT
system, which have major shortcomings.
The quality of service for over
11 million recipients who receive
€77 billion in benefits depends heavily
on this initiative, as do the efficiency
gains in a division that employs
31,000 people (FTE).
Vague strategic priorities
The last three COG gave the
National Family Benefits Fund (
Caisse
nationale des allocations familiales
, CNAF)
too many objectives without setting any
real priorities. The information system
master plans, which are designed to
implement the COG objectives, have
the same flaws and lack the capacity to
anticipate or respond swiftly. They are
only partially carried out.
Governance shortcomings
The State bears major responsibility
The State is largely responsible for
the weaknesses in the information
system’s management tools. When it
inspired and signed COG that contained
too many objectives, the supervisory
authority
did
not
give
sufficient
consideration to the CNAF’s ability to
achieve them.
Moreover, the State has made a
string of changes to the regulations
without giving sufficient thought to
their consequences in terms of changes
to the information system. Each new
measure requires IT development work,
which the CNAF often has to carry out
as a matter of urgency, setting aside
scheduled work and without proper
knowledge
of
the
operational
constraints. For instance, the State
stipulated that the set of sanctions
applicable to recipients of the active
solidarity income (
Revenu de solidarité
active
, RSA) was to be introduced in
April 2012, even though the CNAF had
Direction and management of the
information system of the general
scheme’s Family Division
74
Summary
of 2012 social security report
said that it could not consider bringing
the scheme in until early 2013.
The CNAF feeling its way
The CNAF must shoulder its
management role and take steps to
conduct these projects more firmly and
rigorously.
Despite a reorganisation of the
network
when
the
process
of
departmentalising
the
CAF
was
finished, splitting up the operational
organisation set up to administer and
upgrade the information system is
detrimental to the division’s efficiency
and
the
transparency
of
its
management.
The CNAF needs to tighten and
clarify its IT governance, develop fewer
projects and drastically simplify the
operational structures.
The
CNAF
is
aware
of
the
drawbacks of a system designed in the
past by a division that was not very
centralised, and plans to reorganise its
system by setting up regional data
processing centres, though without
having thoroughly analysed the location
of these structures.
Management
shortcomings
The Family Division’s IT staff is
spread over numerous organisations and
no-one is sure of the total headcount.
Additionally, for want of criteria for
the distribution of responsibilities
among these structures, IT procurement
contracts are sometimes concluded by
the CNAF and sometimes by the CAF
or the regional data processing centres.
The
result
is
a
confusion
of
responsibilities and the fact that the
CNAF has only patchy knowledge of
the consolidated amount spent on IT.
Worrying delays in
modernisation
Given the number of projects under
way, there does not currently appear to
be sufficient capacity for developing the
main applications.
The CNAF does not yet have a
centralised
tool
for
tracking
the
division’s
IT
resources
and
their
allocation to different projects. The
application it designed in 2006 does not
allow it to carry out this tracking. A
contract
for
“Family
Division
management support” is filling the gap
to some extent.
The CNAF is aware that its current
management software is obsolescent
and problematic, and plans to buy a new
tool
that,
however,
will
not
be
operational until the beginning of the
next COG.
Direction and management of the
information system of the general
scheme’s Family Division
75
Summary
of 2012 social security report
Recommendations
63. Focus the next COG on a
handful of ranked priorities, oblige the
CNAF to allocate the necessary
resources for achieving them, and
carry out an annual performance
review.
64. Consolidate the CNAF’s
role in managing the information
system and ensure that it organises
project management and requirements
specification in accordance with best
practice.
65. Stringently rationalise IT
structures
around
a
significantly
smaller number of centres that are far
more closely linked with the CNAF,
and ban the CAF from undertaking
any local developments.
66. Make adoption of the next
master plan contingent on the CNAF’s
possession of the necessary tools for
monitoring
projects,
available
resources and costs.
67.
Systematically seek the
CNAF’s opinion, beforehand, on the
technical feasibility of any legislative
or regulatory changes affecting it.
77
Summary
of 2012 social security report
Cour des Comptes
18
Daily sickness benefits
paid by the general
scheme
A dynamic expenditure
whose determinants have
not been sufficiently
analysed
The daily sickness benefits paid by
the general social security scheme
amounted to €6.4 billion in 2011.
They have increased by almost 50%
since 2000, from €4.3 billion to
€6.4 billion in 2011. Despite the
substantial sums involved and the
dynamics of this expenditure, which is
only partially linked to the increase in
the total payroll, the amount of analysis
done on sick leave is very insufficient.
For instance, the differences observed
in the frequency and duration of sick
leave between one part of the country
and another remain largely unexplained:
if we take out Paris and the Hauts de
Seine, sick leave ranges from 6.5 to 13.2
days’ paid leave per employee from one
department to the next. This lack of
knowledge
prevents
stakeholders
defining a real regulation policy, which
largely remains to be constructed.
Firmer, steadier direction
needed
A control policy to be redefined
The
numerous
measures
for
controlling the insured lack overall
consistency. Their overlap, disparate
implementation and vague targeting
make the policy difficult to grasp. This
lack of clarity is compounded by
problems of liaison between the funds’
administrative services and those of the
medical consultant. For this reason, it
seems indispensable to redefine the
objectives of these services and the
methods used for controls, especially as
they will be able to use new tools
currently being developed by the health
insurance system.
Given the low rate of fraud detected
in paid sick leave claims, the anti-fraud
policy should be updated to include
tools capable of more systematically
detecting fraud and especially organised
fraud.
Daily sickness benefits paid by the
general scheme
78
Summary
of 2012 social security report
Regulation needed, especially for prescribers
For want of a coherent regulation
approach, steps must be taken to raise
awareness of the issues among all of the
stakeholders - people insured by the
social security system, employers and
doctors - using specific measures for
each stakeholder. Employers should be
involved more closely, given that they
provide extensive complementary cover
for the great majority of employees. In
practice, over 65% of employees are no
longer left without pay for the first three
days of their illness before social
security sickness benefits start to be
paid. But a proactive campaign aimed at
doctors, who initiate the expenditure, is
essential. Measures to regulate sick leave
prescriptions should no longer be
confined to the heavy prescribers or
private
practitioners
alone.
While
general
practitioners
prescribe
an
average of 2,700 days’ sick leave each,
doctors in the tenth decile prescribe
7,900 days.
To ensure that all prescribers are
concerned, targets to regulate sick leave
prescriptions are now included in the
negotiation of the agreement.
Hospital doctors should also be
included in measures to regulate
prescriptions: the difficulty of tracing
prescriptions has so far left them out of
the regulation tools used with private
practice doctors.
Simplify the regulations: a
prerequisite for improving
efficiency and quality
Vital efficiency gains
Managing daily sickness benefits
represents a heavy workload for the
health insurance system. It occupies
5,300 administrative FTEs for all of the
risks - close to 10% of the funds’
workforce - for a benefit that represents
approximately 6% of the total expenses
of the sickness and workplace accident-
occupational disease (
accident du travail-
maladie professionnelle
, AT-MP) divisions.
The complexity of the regulations
results in numerous assessment errors,
with a heavy financial impact (roughly
€50 million in 2011).
Quality of service needs to be improved
The current regulations are also an
obstacle to improving quality of service.
The expected gains from projects to
make the process paperless are today
largely limited by the complexity of the
process, which makes it impossible to
automate
the
assessment
of
a
substantial proportion of the claims
(40% at this stage). This situation also
accounts for the difficulty of shortening
the
average
payment
lead
time
(38.5 days in 2011). Sometimes the lead
time for paying the insured is far too
long and can reach hundreds of days.
This is especially hard for employees in
Daily sickness benefits paid by the
general scheme
79
Summary
of 2012 social security report
difficult circumstances, for whom a
discontinuity in their remuneration has
more serious consequences.
The necessity of a simplification,
which is always talked about and always
postponed, cannot be put off any
longer. This is especially true as it largely
determines the successful outcome of
the nominal social security reporting
project, which was adopted in principle
in 2012 and will become required
practice on 1 January 2016.
This form of reporting is designed
to replace almost all employer social
security
reports,
but
cannot
be
envisaged under the current regulations
without making the procedure more
complicated. Apart from the necessity
of simplifying certain points of the
regulations, especially those concerning
the information that employers are
required to provide in the wages
statement, the simplification project
should also strive to harmonise the basis
used to calculate daily sickness benefits,
maternity benefits and AT-MP benefits,
which is specific to each risk. When the
next
CNAMTS
objectives
and
management agreement is drawn up, the
opportunity
should
be
taken
to
thoroughly modernise a benefit whose
basic
characteristics
have
hardly
changed since the inception of the
social security system.
Recommendations
68. Refine and update studies
on the determinants of sick leave.
69.
Accentuate and extend
initiatives
to
make
the
medical
profession
more
aware
of
its
responsibilities.
This
will
mainly
consist in including an objective of
compliance with the prescription
guidelines in private practice doctors’
performance-based remuneration, and
making hospital doctors, and especially
heavy
prescribers,
subject
to
regulation.
70. Evaluate and redefine the
principles for running administrative
checks on the insured. Redefine the
objectives and the methods for
medical checks in terms of targeting
and consistent practices.
71. Introduce the tools and
methods necessary for systematically
detecting
fraud
and
especially
organised fraud.
72. Modernise and simplify the
regulations, essentially by harmonising
the basis used for calculating the
different types of daily sickness
benefits.