Case Study: Primary Care Delivery in France
According to the WHO’s 2008 health report for France, the country doctor has been an integral part of French rural life since the time of King Louis XIV (1638-1715), attending to the basic health needs of villagers.
The WHO has identified several developments, however, that threaten to erode the role of the country doctor in France – a key one being the difficulty of recruiting young doctors for rural areas due to perceived harder working conditions. In central and south-western France, in particular, hundreds of practices closed between 1996–2001 when the local doctor retired.
In a report published in 2000, the WHO ranked France’s health care system as one of the best in the world. In 2006, average life expectancy for women in France was 84 years (one of the highest in the world) and 77 years for men. Currently, the country has a population of 66.9 million.
The system is constituted to ensure equitable geographical coverage and efficient interaction between the different sectors (i.e. public and private hospitals, private practitioners, medical auxiliaries, the pharmaceutical industry).
According to the more recent ‘France: Health system review’ (2015), from the European Observatory on Health Systems and Policies (Health Systems in Transition, 2015; 17(3): 1–218), France has a high level of choice of health providers, and a high level of satisfaction with the health system. However, unhealthy habits such as smoking and harmful alcohol consumption remain significant causes of avoidable mortality.
Although the French healthcare system is a social insurance system, it has historically had a stronger role for the state than other Bismarckian social insurance systems. Public financing of healthcare expenditure is among the highest in Europe and out-of-pocket spending among the lowest.
Public insurance is compulsory in France and covers the resident population; it is financed by employee and employer contributions as well as increasingly through taxation. Complementary insurance plays a significant role in ensuring equity in access. Provision is mixed; providers of outpatient care are largely private, and hospital beds are predominantly public or private non-profit-making.
Despite health outcomes being among the best in the European Union, the European Observatory on Health Systems and Policies has highlighted the social and geographical health inequities that exist – in particular, inequality in the distribution of healthcare professionals, which it says is a considerable barrier to equity. The rising cost of healthcare and the increasing demand for long-term care – like in so many other countries – is also of concern.
Healthcare expenditure in France has grown more rapidly than the economy as a whole for many years. It rose from 10.4% of gross domestic product (GDP; produit intérieur brut) in 1995 to 11.6% in 2013. This is well above the EU average of 9.5%, and in Europe, second only to the Netherlands.
Just over three-quarters of total healthcare expenditure is publicly funded (77%; just above the EU average of 76%), principally through statutory health insurance (SHI).
The proportion of costs covered by SHI varies across goods and services: from 15% for drugs with low medical benefit (service medical rendu; SMR) to 80% for inpatient care. However, there are several conditions for which patients are exempted from paying a part of the costs, such as chronic conditions or pregnancy after the fifth month. Additional co-payments that are not allowed to be covered by voluntary health insurance (VHI; assurance complémentaire) have been created with the aim of reducing demand and thus SHI expenditure.
VHI provides complementary insurance, such as for co-payments and better coverage for medical goods and services that are poorly covered by SHI. It finances 13.8% of total health expenditure and covers more than 90% of the population.
Since 2000, publicly financed complementary universal health coverage (couverture maladie universelle complémentaire; CMU-C) has been offered to those on lower incomes; it covers 7% of the population.
Delivery of care is mixed, including private, fee-for-service (FFS; rémunération à l’acte) physicians, public hospitals, private non-profit-making hospitals and private profit-making hospitals.
Management of the health system is split between the state and statutory health insurance (SHI; assurance maladie). Since the mid-1990s, reforms have aimed to devolve power from the national to the regional level, in particular for planning. Regional institutions were created to represent the main stakeholders: SHI schemes, the state, health professionals and public health actors.
Since the mid-1990s, reforms have aimed to devolve power from the national to the regional level. However, to improve the system’s governance, responsiveness to needs and efficiency, the 2009 Hospital, Patients, Health and Territories (HPST) Act (Loi No. 2009–879 du 21 juillet 2009 portant réforme de l’hôpital et relative aux patients, à la santé et aux territoires) merged most of these institutions into a single regional health agency (agence régionale de santé; ARS).
At the regional level, the ARSs coordinate ambulatory and hospital care for the population as well as health and social care for the elderly and the disabled through a regional strategic health plan (Plan stratégique régional de santé; PSRS) based on population needs.
In general, in the ambulatory care sector, patients pay providers directly and are reimbursed by SHI, although there are exceptions for the most expensive care as well as for households with low incomes; currently 35% of ambulatory payment is paid directly from the insurer to the provider.
Primary and secondary healthcare that does not require hospitalisation is delivered by self-employed doctors, dentists and medical auxiliaries (including nurses and physiotherapists) working in their own practices, and, to a lesser extent, by salaried staff in hospitals and health centres.
Office-based consultations form the basis of GPs’ work, but home visits are also significant, representing about 15% of their work.
Outpatient care and examinations in hospitals represent about 15% of all outpatient consultations. Around 1,700 health centres, usually run by local authorities or mutual insurance associations, along with some organisations offering free treatment to disadvantaged groups, are also active in the delivery of outpatient care, albeit on a marginal basis. These centres are either specialised centres involved in nursing (40%), dental care (25%) or general practice (about 5%) activities, or integrated centres providing all kinds of ambulatory care (about 30%).
According to researchers from the Paris-based Institut de Recherche et Documentation en Économie de la Santé (IRDES), the 2004 French law implementing the ‘Preferred Doctor’ scheme and the coordinated healthcare pathway, the recognition of general medicine as a medical specialisation, the increasing zoning of health policies and the definition of first contact care by the ‘Hospital, Patients, Health and Territories’ Bill project are all witness to a “reorganisation of the ambulatory care sector along the principles of primary care” (‘Three Models of Primary Care Organisation in Europe, Canada, Australia and New-Zealand’, Questions d’économie de la Santé, No 141 – April 2009).
According to a policy briefing document from the London School of Economics and Political Science (‘Primary care in Europe’, Masseria C et al, 2009), the average number of patients per GP in France is between 1,000 and 1,500 – a patient friendly ratio only bettered in Austria and Belgium.
Patients in France are free to choose their healthcare providers, although the level of SHI coverage for physician visits depends upon whether the rules of the gatekeeping structure are followed.
Doctors are also free to choose where they wish to practise, and geographical disparities in the distribution of doctors have long existed.
Nursing care is mainly provided by self-employed nurses. Nursing and home care of patients makes up two-thirds of their work, with another third devoted to technical activities such as performing injections or intravascular perfusions.
Almost all dentists are self-employed in ambulatory practices, as are the majority of physiotherapists, speech therapists and orthoptists.
There are some 22,000 pharmacies, which provide advice and health information in addition to dispensing drugs, small medical devices and bandages. Under the 2009 HPST Act, the role of pharmacists within the primary care system was acknowledged and formalised.
Continuity of care
Lack of coordination and continuity of care is a weakness of the French healthcare system, and various initiatives have sought to address this problem. These include the gatekeeping structure developed under the 2004 Health Insurance Act, which introduced the concept of the ‘preferred doctor’ to coordinate care as the patient’s point of contact within the health system.
France’s electronic patient record, or dossier médical personnel (DMP) – finally rolled out on a national basis in 2011 – was also designed to centralise patient information to facilitate care by multiple health professionals across different settings.
Provider networks to provide multidisciplinary care to patients with complex needs have also been developed, and more recently, attention has been focused on the development of care pathways for patients over age 75 years who are at risk of dependency.
From the late 1990s, GPs have taken on a major role in the coordination of care through a semi-gatekeeping system that provides incentives to people to visit their GP prior to consulting a specialist.
However, patients may designate the treating physician of their choice and, once a specialist referral is made, may visit any professional in that specialty even if it is not the specialist identified by the gatekeeper. In addition, patients can always visit another GP or a specialist without referral even though they are entitled to lower levels of reimbursement if they do so.
The continuity of care system in France is designed to provide a timely and appropriate response to patient needs at night and on weekends or public holidays when ambulatory practices are closed. The system, which now falls under the remit of the ARSs, relies on GPs who are on-call on a voluntary basis and are paid allowances.
However, the number of doctors volunteering to be on-call in the continuity of care system has diminished in recent years, thereby weakening coverage and shifting a growing share of the burden to hospital emergency services
The 750 emergency care structures (structure des urgences) situated in 655 hospitals (76% public, 6% non-profit-making and 18% private) are the cornerstone of the French emergency care system. Certain hospitals have several emergency structures, and overall 85% are general units and 15% paediatric units. They are subject to authorisation by the ARSs.
Yet there is there an increasing emphasis on alternatives to traditional emergency care settings. For example, the number of urgent ambulatory care centres (maisons médicales de garde) providing after-hours care without an appointment has increased over the past 10 years, from 98 in 2003 to 369 in 2013, through expanded public financial incentives.
In 2009, SHI began to offer individual contracts on a voluntary basis to GPs that provided incentives for practice improvement. In 2011, this pay-for-performance (P4P; rémunération à la performance) scheme based on public health objectives (rémunération sur objectifs de santé publique; ROSP) was incorporated into the physicians’ collective bargaining agreement with an expanded list of objectives and extended to additional specialties. GPs participating in ROSP receive additional remuneration on top of their normal income, which takes into account the size of the population treated by the doctor and 29 quality indicators with intermediate and final targets. Overall, the amount earned may exceed €7,000 per year for a doctor achieving over 85% of the targets and treating more than 1,200 patients. There is no penalty for the GPs who do not achieve the targets. In 2012, more than 89,000 physicians participated in the programme, receiving an average annual remuneration of €4,215.
Extra-billing is permitted for doctors practising in so-called ‘Sector 2’, which includes 42% of specialists and 11% of GPs. In France, doctors choose to be in either Sector 1 and adhere to negotiated fees, Sector 2 and be allowed to charge higher fees within reason, or Sector 3 and have no fee limits (a very small percentage of physicians).
In an effort to discourage excessive extra-billing, a ‘carrot and stick’ approach was taken in a 2012 amendment to the collective bargaining agreement between SHI and physician unions. Since 2013, Sector 2 doctors may be subject to sanctions for excessive extra-billing, defined as fees in excess of 150% of official SHI tariffs. In addition, a voluntary three-year ‘Access to Health Care’ contract (contrat d’accès aux soins) provides Sector 2 doctors with incentives to freeze their fees and average rate of excess billing at 2012 levels and to perform a share of their services at statutory tariff levels.
The national convention with pharmacists signed in April 2012 included P4P incentives. The indicators upon which the remuneration is based include increasing the rate of generic substitution for a list of 30 drugs, with an overall goal of 85%.
France Primary Health Care in Action, World Health Report 2008 – Country examples, http://www.who.int/whr/2008/media_centre/france.pdf?ua=1.
‘France: Health system review’ (2015), European Observatory on Health Systems and Policies, Health Systems in Transition, 2015; 17(3): 1–218.
‘Primary care in Europe’, Policy Brief, London School of Economics and Political Science, Masseria C et al, 2009.
‘Three Models of Primary Care Organisation in Europe, Canada, Australia and New-Zealand’, Bourgueil Y et al, Questions d’économie de la Santé, No 141 – April 2009.