The French Connection

The French health care system is viewed by some as the best in the world; multiple payers combine to provide universal care for all of France’s legal residents under the principle of social solidarity.

"Touring Eiffel" by KLMircea (via Flickr | Creative Commons)At the turn of the millennium, the French health care system was touted the best performer in the world according to the World Health Organization. Its universal, multi-payer health care system provides service to all legal residents of France based on a culture rich in social solidarity. It remains the envy of many other nations across the globe.

The French system is delivered through several sickness insurance funds based on an individual’s occupation and geographic location within the country. Additionally, up to 90 percent of the French population has voluntary supplemental insurance on top of the compulsory insurance offered through the sickness funds. The French healthcare system is financed via specifically earmarked taxes (on income, pharmaceutical companies, and tobacco/alcohol) and payroll deductions (up to about 13 percent).

Physicians practice in one of two sectors. Sector I physicians follow a national fee schedule; physicians participating in this program are entitled to certain government benefits including health insurance. Sector II physicians can charge rates above the national fee schedule but do not receive government benefits. Patients traditionally have had a free choice of doctors – both generalists and specialists. However lately, the French have tried to restrict this open access model of care. The goals of such restrictions were to reduce the utilization of services, specifically specialist care.

Since 2006, the French have initiated a form of gate-keeping (known as the “preferred doctor scheme”) which requires patients to initiate interactions with the medical system by visiting a pre-defined primary physician. Implementation of the preferred doctor scheme provided incentive payments for physicians and penalized patients if they went directly to specialists without referrals form their primary care doctor.

However, political scientists note that the preferred doctor scheme established in France was largely a political move and not one based on empirical evidence or thought. The need for a greater role of primary care in the French system was doubtful; up to 90 percent of patients within the French system could already identify a primary care physician even before implementation of the preferred doctor scheme. Upon implementation of the scheme, 81 percent of French patients choose to participate. In fact, when compared to patients that did not agree to join the preferred doctor scheme, those that did agree to participate in the gate keeping process were over 5 times more likely to already have a primary care doctor. Age greater than 65, having complimentary insurance, and poor health status were other factors correlating with an increased likelihood of participation in the preferred doctor scheme.

Following implementation of the preferred doctor scheme, no appreciable reduction in health costs were produced. Similarly, no changes in health care quality were noted.

Commentary

France implemented reforms in 2006 that made good political sense but likely were unnecessary if the government had conducted a thorough needs assessment. While the basis for any health care system should rest on a firm foundation of primary care – doctors who can coordinate care among different specialists – the French system already celebrated a heavy investment in primary care. Therefore, a formalized system of “gate keepers” or “preferred doctors” was unnecessary in the French system where at least 90 percent of patients already had primary care physicians.

The French experience does suggest that while the united States should attempt to reinforce primary care, costs may not be reduced and quality may not be improved once a minimal level of attainment has been reached. What that percentage is however, remains unknown.

Health Policy. 2010; 94: 129–134.

by

Cedric K. Dark, MD, MPH

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