status quo of quo vadis? - KCE

22 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76
2.4.1 France
2.4.1.1 Organisation of the health care system, with focus on general practice
The French health system attempts to keep a balance between values like equity,
freedom and efficiency. All inhabitants are insured since the implementation of the
Universal Coverage Act in 2000 (CMU: Couverture Maladie Universelle). Most people
(95 percent of the population) are covered by the ‘régime général’.
The system is tax and contribution based. Contributions based on earnings (employers
and employees contributions) are completed by social contribution (‘Cotisation Sociale
Généralisée’): this part is based on total income and covers 87.7% of the fluxes. The
professional bodies are mainly concerned with ethical and professional practice and
practice guidelines are upon the responsibility of the HAS. Furthermore, six unions are
competent to sign agreements with the insurance funds. Only 29 percent of GPs are
union members.
The share of the GDP on health care expenditure rose considerably, from 8.1% in 1980
to 11% in 2004. Since 1996 (the Jupé reform) there is national ceiling for health
insurance expenditure (‘Objectif National de Dépenses d´Assurance Maladie’). From
1971 onwards, doctors may enter in a ‘conventionnement’ that ceils their prices.
Otherwise, they lose social and tax advantages. Agreements were signed in 1997
between the insurance funds and the GPs but they were not possible with the
specialists. 83 This situation improved in 2005 with the signing of a new national
‘convention’ with professional unions of GPs and specialists.
In France, patients have a freedom of choice for health professionals. Outpatient care is
mostly provided by self-employed physicians in a fee-for service system. A GP has on
average 1400 patients and about 4800 patient contacts per year, including home visits
(about 25 percent). 83
The patients choose a ‘main doctor’ (GP or specialist). They get a higher
reimbursement when this physician refers them to others specialists than if they go
straightforward to another specialist. This could be compared to some kind of
gatekeeping system but without any patient list. The patients can change of ‘main
doctor’ anytime they want without any consequence. This ‘gatekeeping system’ does
not value the central role of a GP.
The computerisation of medical records is hampered by the lack of budget and mostly
by the resistance of physicians who are afraid of any external control.
The health system combines public and private care, including for-profit hospital care. In
the Jupé reform (1996), doctors are co-responsible for exceeding the budgets.
However, the budgets exceeding the targets never gave rise to any refunds by
doctors. 83
In summary, the characteristics of the French primary health care system are the
following:
• A fee for service system;
• A diversified liberal offer (general practitioners, hospital emergency rooms,
specialists, health centres);
• An abundant offer but unequally distributed;
• The freedom of choice for the patient;
• An insufficient coordination between health professionals and between
primary and hospital care, despite of some local efficient networks.