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80 Economic crisis, health systems and health in Europe: country experience
a multiyear basis and, therefore, tend to be fixed for a given period of time,
and there is no a-priori control of the volume of care consumed. However,
more recent measures have attempted to make the national ceiling for SHI
expenditure into a harder form of budget capping. The first measure was the
creation of the Alert Committee in 2004 and the group for the statistical
monitoring of the national ceiling in 2010, while the second gave the head of
the Directorate of Social Security the power to present a financial rescue plan
when the overrun exceeds 0.6% of SHI expenditure or to introduce correcting
interventions during the year.
These correcting interventions included, for example, a decrease in hospital
tariffs for diagnostic-related groups (DRGs) set by the Ministry of Health (public
and private hospitals are the responsibility of the Ministry of Health, and hence
it sets the DRG tariffs) and a freeze in the share of budgets dedicated to the
Quality and Coordination of Care Fund (Fonds d'intervention pour la qualité
et la coordination des soins), to the social and health care sector and, finally,
to the hospital block grant for the Public Utility Mission (Mission d’intérêt
général et d’aide à la contractualisation), which is dedicated to the coordination
of care, research and teaching, plus epidemiological surveillance and expertise.
However, strikingly, these measures barely touched goods and services delivered
or prescribed on a private basis by self-employed professionals, despite the fact
that the overrun was greatest in this area. For example, of the €930 million that
was spent in excess of the overall target in 2008, €800 million came from the
private practice subarea of expenditure, while only €130 million came from the
hospital sector.
Finally, France faces the pressure of a rapidly growing ageing population, resulting
from increasing life expectancy (but not from declining fertility rates). The baby
boom effect after the Second World War will exacerbate this trend in the medium
term. Because the probability of becoming dependent greatly increases with age,
the number of frail older people is expected to grow 40% by 2030 and 60% by
2060, rising from 1.15 million in 2010 to 1.55 million in 2030 and 2.3 million
by 2060, corresponding to an estimated 3% of the population (Charpin &
Tlili, 2011). As a result, there is an increasing need for long-term care to provide
personal assistance to frail older people at home, in nursing facilities or in other
residential care settings. While the social security system was the main funding
source for long-term care after its creation, since the 1970s, the local authorities'
responsibility for funding long-term care has grown following the creation of
a universal allowance with a means-tested co-insurance. Overall, this can be
regarded as a shift from national solidarity-based financial protection to local taxbased
financial protection, increasing geographical inequity. Moreover, this shift
in long-term care financing is regressive, as a share of local taxes is not income
based (Chevreul & Berg Brigham, 2013).