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France, like other countries in Europe, has a system of universal health care largely financed by government through a system of national health insurance. In its 2000 assessment of world health care systems, the World Health Organization found that France provided the "best overall health care" in the world.[1] In 2005, France spent 11.2% of GDP on health care, or US$3,926 per capita, a figure much higher than the average spent by countries in Europe and less than in the US. Approximately 77% of health expenditures are covered by government.[2]

Most general physicians are in private practice but draw their income from the publicly funded insurance funds. These funds, unlike their German counterparts, have never gained management responsibility. Instead the government has taken responsibility for the financial and operational management of health insurance (by setting premium levels related to income and determining the prices of goods and services refunded).[1] It generally refunds patients 70% of most health care costs, and 100% in case of costly or long-term ailments. Supplemental coverage may be bought from private insurers, most of them nonprofit, mutual insurers. Until recently, social security coverage was restricted to those who contributed to social security (generally, workers or retirees), excluding some poor segments of the population; the government of Lionel Jospin put into place "universal health coverage" and extended the coverage to all those legally resident in France. Only about 3.7% of hospital treatment costs are reimbursed through private insurance, but a much higher share of the cost of spectacles and prostheses (21.9%), drugs (18.6%) and dental care (35.9%) (Figures from the year 2000). There are public hospitals, non-profit independent hospitals (which are linked to the public system), as well as private for-profit hospitals.

Average life expectancy at birth is 81 years.[3][4]

Contents

Health care system

The entire population must pay compulsory health insurance. The insurers are non-profit agencies that annually participate in negotiations with the state regarding the overall funding of health care in France. There are three main funds, the largest of which covers 84% of the population and the other two a further 12%. A premium is deducted from all employees' pay automatically. The 2001 Social Security Funding Act, set the rates for health insurance covering the statutory health care plan at 5.25% on earned income, capital and winnings from gambling and at 3.95% on benefits (pensions and allowances).[5]

After paying the doctor's or dentist's fee, a proportion is claimed back. This is around 75 to 80%, but can be as much as 85%. The balance is effectively a co-payment paid by the patient but it can also be recovered if the patient pays a regular premium to a voluntary health insurance scheme. Nationally, about half of such copayments are paid from VHI insurance and half out of pocket. Under recent rules (the coordinated consultation procedure [in French: parcours de soins coordonné]) General practitioners ("médecin généraliste" or "docteur") are more expected to act as "gate keepers" who refer patients to a specialist or a hospital.[citation needed] The incentive is financial in that expenses are reimbursed at lower rates for patients who go direct to a specialist (except for dentists, ophthalmologists, gynecologists and psychiatrists).

As costs are borne by the patient and then reclaimed, patients have freedom of choice where to receive care.[citation needed] Around 65% of hospital beds in France are provided by public hospitals, around 15% by private non-profit organizations, and 20% by for-profit companies.[citation needed]

Minister of Health and Solidarity is a cabinet position in the government of France. The health portfolio oversees the healthcare public services and the health insurance part of Social Security. As ministerial departments are not fixed and depend on the Prime Minister's choice, the Minister sometimes has other portfolios among Work, Pensions, Family, the Elderly, Handicapped people and Women's Rights. In that case, they are assisted by junior Ministers who focus on specific parts of the portfolio. The current Minister is Roselyne Bachelot-Narquin.

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Fees and reimbursements

Act Fee  % reimbursed Patient charge
Generalist consultation 22 € 70 % 6,60 €
Specialist consultation 25 € 70% 7,50 €
Psychiatrist consultation 37 € 70% 11,10 €
Cardiologist consultation 49 € 70% 14,17 €
Filling a cavity 19,28 € - 48,20 € 70% 5,78 € - 14,46 €
Root canal 93,99 € 70% 28,20 €
Teeth cleaning 28,92 € 70% 8,68 €
Prescription Medicine variable 35 - 100 % variable
30 Advil 200 mg 2,51 € 60 % 1,00 €

Médecin généraliste

The médecin généraliste (commonly called docteur) is responsible for long-term care in a population. This implies prevention, education, care of diseases and traumas that do not require a specialist. They also follow severe diseases day-to-day (between acute crises that require a specialist).

They survey epidemics, a legal role (consultation of traumas that can bring compensation, certificates for the practice of a sport, death certificates, certificates for hospitalization without consent in case of mental incapacity), and a role in emergency care (they can be called by the samu, the emergency medical service). They often go to a patient's home when the patient cannot come to the consulting room (especially in case of children or old people), and have to contribute to night and week-end duty.

Health insurance

Because the model of finance in the French health care system is based on a social insurance model, contributions to the scheme are based on income. Prior to reform of the system in 1998, contributions were 12.8% of gross earnings levied on the employer and 6.8% levied directly on the employee. The 1998 reforms extended the system so that the more wealthy with capital income (and not just those with income from employment) also had to contribute, since when the 6.8% figure has dropped to 0.75% of earned income. In its place a wider levy based on total income has been introduced, gambling taxes are now redirected towards health care and recipients of social benefits also must contribute.[6] Because the insurance is compulsory, the system can effectively be thought to be financed by taxation rather than traditional insurance (as typified by auto or home insurance, where risk levels determine premiums).

The founders of the French social security system were largely inspired by the Beveridge report in the United Kingdom, and aimed to create a single system guaranteeing uniform rights for all. However, there was much opposition from certain socio-professional groups who already benefited from the previous insurance coverage that had more favourable terms. These people were allowed to keep their own systems. Today, 95% of the population are covered by 3 main schemes. One for commerce and industry workers and their families, another for agricultural workers and lastly the national insurance fund for self-employed non-agricultural workers.[6]

All working people are required to pay a portion of their income to a health insurance fund, which mutualised the risk of illness, and which reimbursed medical expenses at varying rates. Children and spouses of insured people were eligible for benefits, as well. Each fund was free to manage its own budget and reimburse medical expenses at the rate it saw fit.

The government has two responsibilities in this system.

  • The first government responsibility is the fixing of the rate at which medical expenses should be negotiated, and it does this in two ways: The Ministry of Health directly negotiates prices of medicine with the manufacturers, based on the average price of sale observed in neighboring countries. A board of doctors and experts decides if the medicine provides a valuable enough medical benefit to be reimbursed (note that most medicine is reimbursed, including homeopathy). In parallel, the government fixes the reimbursement rate for medical services : this means that a doctor is free to charge the fee that he wishes for a consultation or an examination, but the social security system will only reimburse it at a pre-set rate. These tariffs are set annually through negotiation with doctors' representative organisations.
  • The second government responsibility is oversight of the health-insurance funds, to ensure that they are correctly managing the sums they receive, and to ensure oversight of the public hospital network.

Today, this system is more-or-less intact. All citizens and legal foreign residents of France are covered by one of these mandatory programs, which continue to be funded by worker participation. However, since 1945, a number of major changes have been introduced. Firstly, the different health-care funds (there are five : General, Independent, Agricultural, Student, Public Servants) now all reimburse at the same rate. Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). This regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference. Finally, to counter the rise in health-care costs, the government has installed two plans, (in 2004 and 2006), which require insured people to declare a referring doctor in order to be fully reimbursed for specalist visits, and which installed a mandatory co-pay of 1 € (about $1.45) for a doctor visit, 0,50 € (about 80 ¢) for each box of medicine prescribed, and a fee of 16-18 € ($20–25) per day for hospital stays and for expensive procedures.

An important element of the French insurance system is solidarity : the more ill a person becomes, the less they pay. This means that for people with serious or chronic illnesses, the insurance system reimburses them 100 % of expenses, and waives their co-pay charges.

Finally, for fees that the mandatory system does not cover, there is a large range of private complementary insurance plans available. The market for these programs is very competitive, and often subsidised by the employer, which means that premiums are usually modest. 85% of French people benefit from complementary private health insurance.[7][8]

Quality

A government body, ANAES, Agence Nationale d'Accréditation et d'Evaluation en Santé (The National Agency for Accreditation and Health Care Evaluation) is responsible for issueing recommendations and practice guidelines. There are recommendations on clinical practice (RPC), relating to the diagnosis, treatment and supervision of certain conditions, and in some cases, to the evaluation of reimbursement arrangements. ANAES also publishes practice guidelines which are recommendations on good practice that doctors are required to follow according to the terms of agreements signed between their professional representatives and the health insurance funds.There are also recommendations regarding drug prescriptions, and to a lesser extent, the prescription or provision of medical examination. By law, doctors must maintain their professional knowledge with ongoing professional education.[6]

Emergency medicine

Private Ambulance in Pontarlier

Ambulatory care includes care by general practitioners who are largely self employed and mostly work alone, although about a third of all GPs work in a group practice. GPs do not exercise gatekeeper functions in the French medical system and people can see any registered medical practitioner of choice including specialists. Thus ambulatory care can take place in many settings.

Hospitals

About 62 per cent of French hospital capacity is met by publicly owned and managed hospitals. The remaining capacity is split evenly (18% each) between the non-profit sector hospitals (which are linked to the public sector and which tend to be owned by foundations, religious organizations or mutual insurance associations) and by the for-profit institutions.[6]

Public health

France, as all EU countries, is under an EU directive to reduce sewage discharge to sensitive areas. In 2006, France was only 40% in compliance, one of the lowest achieving countries in the EU with regard to this wastewater treatment standard [9]

See also

References

  1. ^ a b World Health Organization Assesses the World's Health Systems
  2. ^ The World Health Report 2000: WHO
  3. ^ Organisation for Economic Co-operation and Development (pdf), OECD Health Data 2008: How Does Canada Compare, http://www.oecd.org/dataoecd/46/33/38979719.pdf, retrieved 2009-01-09 .
  4. ^ Updated statistics from a 2009 report
  5. ^ http://www.euro.who.int/document/e83126.pdf WHO Health care systems in transition:France (WHO)
  6. ^ a b c d http://www.euro.who.int/document/e83126.pdf Health Care Systems in Transition - France: WHO
  7. ^ "L'assurance maladie"
  8. ^ John S. Ambler, "The French Welfare State : surviving social and ideological change," New York University Press, 30 Sept 1993, ISBN 978-0814706268
  9. ^ "Water - a precious resource". European Environment Agency. 2004. http://epaedia.eea.europa.eu/page.php?pid=501. Retrieved 2008-03-13. 

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