Introduction
France is a state in Western Europe, the country of parliamentary democracy headed by the president and a bicameral parliament consisting of the National Assembly and the Senate (Moulis et al., 2015). The state of the healthcare system in France is difficult to assess unequivocally; the role of the government is high since most of the innovations are sponsored by the authorities. Moreover, the system of health insurance is controlled by the government, and in case of controversial issues, state boards come to a conclusion regarding this or that solution (Chevreul, Brigham, Durand-Zaleski, & Hernández-Quevedo, 2015). Any medical service in France is provided based on medical insurance, which can be of two types – compulsory and voluntary (Liaropoulos & Goranitis, 2015). The payment of medical services can also be carried out with the involvement of insurers. At the same time, a wide range of services is offered, and patients can independently choose their doctors and consult them. However, the gatekeeping process is strict enough, and particular reforms were implemented to control the population’s interests and preferences regarding physicians. Therefore, there is a need to assess the condition of the country’s healthcare system in more detail, determine what levers are key ones in defining the current policy, and consider proposing some improvements borrowed from the healthcare systems of other countries.
The Extent of Using the Policy Levers
The French healthcare system is of a mixed type. Its structural system is based on the Bismarck approach with the goals formulated by Beveridge (Checherita-Westphal, Hallett, & Rother, 2014). It is reflected in the existence of a single-payer system, the increasing role of budgetary sources of health financing, and the strong influence of the state (Organisation for Economic Co-Operation and Development, 2015). Among the primary current levers that determine the development of the country in the field of healthcare, it is possible to single out the side of supply, the demand side, the features of management and financing, and all the revenues.
State health insurance in France is compulsory and covers 89% of the population (Organisation for Economic Co-Operation and Development, 2015, p. 22). The amount of contributions is set by the state, and funds are collected by local social security departments. Their level is quite high – about 19.4% of wages (Organisation for Economic Co-Operation and Development, 2015, p. 66). However, employees pay only a third of the amount, and all the rest is paid by employers. If an accident occurs at work, 100% of expenses are covered, under other circumstances, 75% is compensated, and the rest is paid by the patient independently (Organisation for Economic Co-Operation and Development, 2015, p. 161). This universal principle also applies when paying for doctors’ visits, when buying drugs in a pharmacy, and when passing diagnostic tests and procedures.
Supply Side of the French Healthcare System
In France, medical facilities, equipment, and other material resources are in good condition. However, there are significant regional differences in the distribution of these resources (Choné, 2017). There are four main categories of hospitals: regional, general, local, and psychiatric. Capital investments are either covered by reimbursement of expenses for provided services or carried out within the framework of targeted programs. Over the past ten years, two national investment programs have been adopted to achieve standards of safety and quality of care (Hassenteufel & Palier, 2015). Regional health agencies are responsible for controlling capital investments and purchasing basic medical equipment.
Forecasting of human resources and careful planning of training is conducted mainly at the state level. According to Gusmano et al. (2014), it is achieved utilizing the mechanism of interest rate in educational institutions for medical workers, which helps to avoid the shortage or overabundance of specialists. However, it does not provide control over the regional distribution of personnel since self-employed workers are not limited to choosing their place of work. As Kulesher and Forrestal (2014) remark, to overcome regional disparities in the distribution of health workers, some of the doctors’ functions were assigned to nurses, and additional incentives were introduced to attract medical personnel to areas where a severe shortage of specialists was observed.
There are some problems with the competition. Thus, there is competition among medical providers, which does not always have a positive effect on the quality of their services. Also, budgetary fees are an integral part of the healthcare system, and these costs can be expensive for poor citizens. Moreover, providers’ payment methods are non-standard; the prices are separate for each type of treatment, and a complex system of third-party involvement is often used (Organisation for Economic Co-Operation and Development, 2015). Therefore, the supply side should be improved, and specific measures can be introduced in this sphere.
Demand Side of the French Healthcare System
The demand side is an essential lever. Increasing regional equity in access to healthcare and demand for long-term care are the primary areas that have been affected by recent health reforms in France (Dylst, Vulto, & Simoens, 2014). In the government work plan, special attention is paid to the growing demand for long-term medical care. At the same time, despite the authorities’ significant support for the increase in the volume of services, two main challenges remain: to make the sector more attractive to employees and to provide for the state coverage of long-term care for the elderly to ensure more equitable access (Godman et al., 2014). These issues should be resolved to make the system more developed.
The introduction of a regional health strategic plan contributed to the creation of a common approach to planning for inpatient, outpatient, and medico-social sectors. Besides, this law provided for a formal basis for redistributing responsibilities among medical personnel (Salter, Zhou, & Datta, 2015). These measures also helped to regulate the regional percentage rate in educational institutions for medical workers, bringing it in line with the need for employees. For example, according to Sicsic and Franc (2017), there is an increase in the salaries of physicians in the hospitals of those specializations that are most needed. Also, contracts are signed voluntarily with graduates of medical faculties and self-employed specialists. These measures provide incentives for physicians’ work in those country’s regions that are least provided with medical services.
One of the issues that deserve special attention is the patient’s ability to choose doctors. The organizers of the French healthcare concluded that to better coordinate general therapeutic and specialized medical care, it is necessary to take measures to regulate the choice of the physician by the patient (Salter et al., 2015). Nevertheless, this problem creates some difficulties for the organization of access to specialists of a certain profile.
The difference in the amount of money spent by the patient for medical services and compensated by the fund is paid the insured or an additional insurer. Before the adoption of the relevant reform, low-income people who could not afford the additional insurer’s services had significant healthcare costs. The proportions in the cost-sharing vary depending on the type of care. Patients with chronic diseases and poor people are exempt from additional payments. However, the gatekeeping process is strict enough, and authorities control all the funds that are spent on specific spheres and come to the budget as revenues. Therefore, the demand side of the French healthcare system is being developed, and appropriate successful steps are being implemented.
Public Management, Coordination, and Financing
In France, medicine financing is mainly provided through the system of compulsory health insurance (CHI). However, the CHI accounts for only three-quarters of healthcare expenditure, leaving platforms for additional sources of funding, such as voluntary health insurance (Liaropoulos & Goranitis, 2015). Inclusion in the CHI system is based on the principle of citizenship, and this principle covers a wide range of medical services and supplies. The level of coverage for services and goods included in the CHI program varies and can be different for drugs and inpatient care. However, as Dormont and Péron (2016) note, patients are excluded from the co-insurance system under specific conditions. It can be, for example, because of chronic diseases or late pregnancy – after the fifth month.
Planning and regulation of the healthcare system are carried out in the process of interaction of some participants. They are the following ones: the representatives of service providers (hospitals and health workers), the state represented by the Ministry of Health and the Ministry of State Budget Accounts, Public Lending and State Reforms, and the CHI system (Stabile & Thomson, 2014). The result of joint work is administrative decisions and laws passed by the Parliament. These laws include regulatory, legal acts in the fields of health, financing of social security, and reforms.
For the last decades, much has changed in the French system. Over the past twenty years, due to the growth in healthcare costs, and the CHI deficit, the role of the state in planning and regulation has significantly increased (Franc & Pierre, 2015). State tariffs are established on the results of negotiations among the representatives of healthcare providers and the CHI system and then are approved by the Ministry of Health (Franc & Pierre, 2015). The quality of care is regulated at the national level. According to Doty, Nadash, and Racco (2015), hospitals are to be certified every four years. At the same time, a formal re-certification or licensing process for health workers is not provided.
Pharmaceutical companies in France today are developing. There is an agreement among the state and medical ventures to ensure that if the budget for medicines is exceeded, pharmaceutical companies reduce prices or partially reimburse surplus spending to the state (Franc & Pierre, 2015). This mechanism establishes prices under the expected or real output, and if it exceeds a certain threshold, the price is reduced or companies should pay a certain amount to the state or insurance organizations. The country’s authorities have entered into agreements at the level of industry in general and the level of individual companies on reimbursement of funds if public expenditures exceed the planned ones. It allows saying that the French healthcare system is stably financed and controlled, even though pharmaceutical prices are still high enough.
Revenue Side of the French Healthcare System
The means of compulsory medical insurance are primarily formed at the expense of contributions of employees and employers. Since the late 1990s, as a result of attempts to expand the financial base of the social insurance system, workers’ contributions depending on the wages have been almost completely replaced (Tambor, Pavlova, Golinowska, & Groot, 2015). They were replaced by a special tax, the so-called “general social contribution,” that is subject to the total income but not only labor activity, as it was before (Tambor et al., 2015, p. 197). As Gastaldi-Ménager, Geoffard, and De Lagasnerie (2016) claim, additional sources of income, which account for about 13% of funds, are specific taxes on tobacco products and taxes on the turnover of pharmaceutical companies (p. 507). It is also a good source of revenue.
Within the framework of the CHI, the reimbursement of expenses for co-payments is carried out. A wider range of inaccessible medical goods and services is provided (Sorenson, Drummond, Torbica, Callea, & Mateus, 2015). Over the past decades, the role of CHI in ensuring equal access to healthcare and its financing has grown (Toumi et al., 2015). Thus, in France, medical facilities, equipment, and other material resources are in good condition. However, there are significant regional differences in the distribution of these resources, which determines the income of the health sector.
Possible Disadvantages and Advantages of Using the Policy Levers
Over the years, the healthcare system of France has been recognized as one of the best in the world (Moulis et al., 2015). It has become synonymous with the universal coverage of medical services and their provision in large volumes (Rechel et al., 2016). It was achieved mainly by accomplishing the following tasks: providing the universal coverage, access without waiting lists, the freedom of choice satisfaction of the patient. The combination of compulsory and voluntary health insurance systems, as well as the purchase of drugs and medical services not adequately covered by the public system, led to a low level of personal expenses of citizens and a high level of consumption of medical care. The average life expectancy of the French is more than 80 years (Rechel et al., 2016). It can be explained by the successful combination of the system of medical care with the well-thought-out policy in the field of public health.
However, despite these positive trends, some shortcomings can also be noted, especially in terms of efficiency and socio-economic inequalities in health. The central problems, as Elshaug et al. (2017) note, are the lack of coordination among inpatient and outpatient services, private and public health service providers, and the healthcare system and public health. To resolve the current issues, it is possible to compare the existing French order of medical services with other world programs.
Possible Improvements to Borrow from Other Countries Applying the Policy Levers to Improve the Current System
As an example of the successful functioning of the healthcare system, it is possible to consider the German experience. In this country, the list of compensated drugs is expanded, and the opportunity for pharmacists to set the cost of medicines is provided, which allows Germany to save significant amounts of money (Davy et al., 2015). The experience of Bulgaria can also be an example of the implementation of the Bismarck health system. According to Stange et al. (2014), before the introduction of the insurance system in Bulgaria, the state healthcare model functioned. Subsequently, the government introduced several innovations, namely, the legalization of private practice and its participation in the CHI system, the restructuring of the primary healthcare sector, the introduction of the Institute of general practitioners, and the use of clinical algorithms for examination and treatment (Steffen, 2016). All these points are successful and effective steps towards the establishment of stable medicine, and the experience of French doctors can also be enriched by using the practice of colleagues from other countries.
French healthcare differs from many in that it focuses on combating bad habits (smoking, alcoholism), as there is a separate tax in the country that requires paying contributions in case of the neglect of one’s health. As Macfarlane et al. (2016) remark, in France, just as in other countries, a search for new ways of treating complex diseases is made, and funds are allocated for conducting experimental studies. However, French authorities can adopt some foreign policies, for instance, the German model to save money. If the government takes into account neighboring countries’ experience, healthcare can become more advanced.
Conclusion
Thus, the key levers of the current healthcare policy in France are the supply, the demand, the management and financing, and the revenue sides. All these levers have their peculiarities, and the supply side needs improvement as there are some disadvantages to it. The emphasis on activities following the insurance policy has certain merits, but some shortcomings are manifested in payment features and the organization of the work of medical providers struggling for more profitable positions in the market. The current approach to forming the system of medicine has enough advantages. Nevertheless, the experience of other healthcare models can be of good use for the French government to establish a strong and reliable system that can meet modern quality standards and satisfy patients.
References
Checherita-Westphal, C., Hallett, A. H., & Rother, P. (2014). Fiscal sustainability using growth-maximizing debt targets. Applied Economics, 46(6), 638-647.
Chevreul, K., Brigham, K. B. Durand-Zaleski, I., & Hernández-Quevedo, C. (2015). France: Health system review. Health Systems in Transition, 17(3), 1-218.
Choné, P. (2017). Competition policy for health care provision in France. Health Policy, 121(2), 111-118.
Davy, C., Bleasel, J., Liu, H., Tchan, M., Ponniah, S., & Brown, A. (2015). Effectiveness of chronic care models: Opportunities for improving healthcare practice and health outcomes: A systematic review. BMC Health Services Research, 15(1), 194-205.
Dormont, B., & Péron, M. (2016). Does health insurance encourage the rise in medical prices? A test on balance billing in France. Health Economics, 25(9), 1073-1089.
Doty, P., Nadash, P., & Racco, N. (2015). Long-term care financing: Lessons from France. The Milbank Quarterly, 93(2), 359-391.
Dylst, P., Vulto, A., & Simoens, S. (2014). Analysis of French generic medicines retail market: Why the use of generic medicines is limited. Expert Review of Pharmacoeconomics & Outcomes Research, 14(6), 795-803.
Elshaug, A. G., Rosenthal, M. B., Lavis, J. N., Brownlee, S., Schmidt, H., Nagpal, S.,… Saini, V. (2017). Levers for addressing medical underuse and overuse: Achieving high-value health care. The Lancet, 390(10090), 191-202.
Franc, C., & Pierre, A. (2015). Compulsory private complementary health insurance offered by employers in France: Implications and current debate. Health Policy, 119(2), 111-116.
Gastaldi-Ménager, C., Geoffard, P. Y., & De Lagasnerie, G. (2016). Medical spending in France: Concentration, persistence and evolution before death. Fiscal Studies, 37(3-4), 499-526.
Godman, B., Wettermark, B., van Woerkom, M., Fraeyman, J., Alvarez-Madrazo, S., Berg, C.,… Gustafsson, L. L. (2014). Multiple policies to enhance prescribing efficiency for established medicines in Europe with a particular focus on demand-side measures: Findings and future implications. Frontiers in Pharmacology, 5, 106-115.
Gusmano, M. K., Weisz, D., Rodwin, V. G., Lang, J., Qian, M., Bocquier, A.,… Verger, P. (2014). Disparities in access to health care in three French regions. Health Policy, 114(1), 31-40.
Hassenteufel, P., & Palier, B. (2015). Still the sound of silence? Towards a new phase in the Europeanisation of welfare state policies in France. Comparative European Politics, 13(1), 112-130.
Kulesher, R. R., & Forrestal, E. E. (2014). International models of health systems financing. Journal of Hospital Administration, 3(4), 127-139.
Liaropoulos, L., & Goranitis, I. (2015). Health care financing and the sustainability of health systems. International Journal for Equity in Health, 14(1), 80-83.
Macfarlane, A. J., Blondel, B., Mohangoo, A. D., Cuttini, M., Nijhuis, J., Novak, Z.,… Zeitlin, J. (2016). Wide differences in mode of delivery within Europe: Risk-stratified analyses of aggregated routine data from the Euro-Peristat study. BJOG: An International Journal of Obstetrics & Gynaecology, 123(4), 559-568.
Moulis, G., Lapeyre-Mestre, M., Palmaro, A., Pugnet, G., Montastruc, J. L., & Sailler, L. (2015). French health insurance databases: What interest for medical research? La Revue de Médecine Interne, 36(6), 411-417.
Organisation for Economic Co-Operation and Development. (2015). Fiscal sustainability of health systems: Bridging health and finance perspectives. Web.
Rechel, B., Džakula, A., Duran, A., Fattore, G., Edwards, N., Grignon, M.,… Smith, T. A. (2016). Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries. Health Policy, 120(7), 758-769.
Salter, B., Zhou, Y., & Datta, S. (2015). Hegemony in the marketplace of biomedical innovation: Consumer demand and stem cell science. Social Science & Medicine, 131, 156-163.
Sicsic, J., & Franc, C. (2017). Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data. The European Journal of Health Economics, 18(5), 609-621.
Sorenson, C., Drummond, M., Torbica, A., Callea, G., & Mateus, C. (2015). The role of hospital payments in the adoption of new medical technologies: An international survey of current practice. Health Economics, Policy and Law, 10(2), 133-159.
Stabile, M., & Thomson, S. (2014). The changing role of government in financing health care: An international perspective. Journal of Economic Literature, 52(2), 480-518.
Stange, K. C., Etz, R. S., Gullett, H., Sweeney, S. A., Miller, W. L., Jaén, C. R.,… Glasgow, R. E. (2014). Metrics for assessing improvements in primary health care. Annual Review of Public Health, 35, 423-442.
Steffen, M. (2016). Universalism, responsiveness, sustainability – Regulating the French health care system. New England Journal of Medicine, 374(5), 401-405.
Tambor, M., Pavlova, M., Golinowska, S., & Groot, W. (2015). Can European countries improve sustainability of health care financing through patient cost-sharing? Frontiers in Public Health, 3, 196-200.
Toumi, M., Rémuzat, C., El Hammi, E., Millier, A., Aballéa, S., Chouaid, C., & Falissard, B. (2015). Current process and future path for health economic assessment of pharmaceuticals in France. Journal of Market Access & Health Policy, 3(1), 1-15.