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FRANCE inequities in prevention related to obesity, screening, and immunization. A contractual agreement allows for the use of incentives for physicians practicing in underserved areas, the extension of third-party payment, and enforced limitations on denial of care. National surveys showing regional variations in health and access to health are reported by the Ministry of Health (DREES, 2015). What is being done to promote delivery system integration and care coordination? Various quality-related initiatives aim to improve coordination of hospital, out-of-hospital, and social care (see above). At the regional level, telemedicine pilot programs are under way to coordinate health and social care services for target populations identified by the Regional Health Agencies, such as infants, prisoners, and persons with disabilities. Funding streams are pooled and earmarked for these pilots, and assessment is planned for 2016. What is the status of electronic health records? A high-level electronic health record (EHR) project is currently being implemented across the entire country. Approximately 551,000 patients, or 0.8 percent of the population, have an EHR, and an estimated 600 hospitals and 6,000 health professionals use them. Hospital-based and office-based professionals and patients have a unique electronic identifier, and any health professional can access the record and enter information subject to patient authorization. Interoperability is ensured via a chip on patients’ health cards. By law, patients have full access to the information in their own records, either directly or through their GP. All “structured information” included in EHRs must be communicated, but handwritten notes are excluded. The sharing of information between health and social care professionals is not currently permitted, but will be tested as part of the PAERPA program for hospice residents. A national agency for health information systems was created for the purpose of expanding uptake and interoperability of existing systems (ASIP, 2014), and the health records are available on a government website. How are costs contained? SHI has faced large deficits over the past 20 years, but it fell from an annual EUR10B–12B (USD12.1B–14.5B) in 2003 to EUR6.2B (USD7.5B) in 2014. This trend is the result of a range of initiatives, including a reduction in the number of acute-care hospital beds; the removal of 600 drugs from public reimbursement; an increase in generic prescribing and the use of over-the-counter drugs; a reduction in the price of generic drugs; and a reduction of the official fees for self-employed radiologists and biology labs. Other cost-containment measures include central purchasing to better negotiate costs, increasing the share of outpatient surgery, and reducing duplicate testing. Competition is not used as a cost-control mechanism. Global budgets are used only in price– volume agreements for drugs or devices. As described above, patient cost-sharing mechanisms include increased copayments for patients who refuse generics or do not use the gatekeeping system (Assemblée Nationale, 2013). A number of initiatives to reduce “low-value” care, launched by SHI and HAS, include pay-for-performance to reduce prescription of benzodiazepines for elderly persons; reductions in avoidable hospital admissions for patients with heart failure; early discharge after orthopedic surgery and normal childbirth; information on the absence of the benefit of prostate cancer screening; using DRG payments to incentivize shifts to outpatient surgery; establishing guidelines for the number of off-work days according to disease or procedure; strengthening controls for the prescription of expensive statins and new anticoagulants; encouraging the use of Avastin over Lucentis, and other less costly biosimilar drugs; and testing the use of taxi vouchers, instead of ambulances, for chronically ill patients (Assurance Maladie, 2015). 66 The Commonwealth Fund
What major innovations and reforms have been introduced? FRANCE The new Health Law, based on the 2012 pledge by the newly elected government to reduce health inequities and on the 2014 health strategy (Touraine, 2014), was passed in April 2015 to replace the previous law, dating back to 2004. It has 57 articles, the most prominent being the deployment of direct SHI payments to selfemployed GPs and a strong commitment to public health and prevention. The direct GP payments have been strongly opposed by physicians’ unions on the grounds that such payments might be delayed by software dysfunction (versus immediate payment at the end of the consultation) and that physicians would become SHI “employees,” and could be pressured into giving cheap care instead of appropriate care. The timetable is to have a full deployment by 2017 (the year of the presidential election). Prevention and public health measures aim to reduce addictions, eating disorders, and obesity, and include measures to fight binge drinking and anorexia. They support the mandatory neutral cigarette pack, the ban on soda fountains, experimentation with medically supervised IV drug injecting facilities, and mandatory nutrition information on packaged foods (Parlement, 2015). References ASIP (2014). http://www.interopsante.org/offres/doc_inline_src/412/4_FranE7ois%2BMacary_ASIP%2BSantE9_Les%2Btests% 2Bd5C27interopE9rabilitE9%2Bpour%2Bla%2Be-santE9%2Ben%2BFrance.pdf?bcsi_scan_43167910db6ab4d9=0&bcsi_scan_ filename=4_FranE7ois%2BMacary_ASIP%2BSantE9_Les%2Btests%2Bd5C27interopE9rabilitE9%2Bpour%2Bla%2BesantE9%2Ben%2BFrance.pdf. Assemblées Nationale. http://www.assemblee-nationale.fr/14/projets/pl2302.asp. Assurance Maladie (2015). Rapport charges et produits pour l’année 2016. http://www.ameli.fr/fileadmin/user_upload/ documents/cnamts_rapport_charges_produits_2016.pdf. Assurance Maladie (2015). http://www.ameli.fr/professionnels-de-sante/medecins/gerer-votre-activite/le-medecin-traitant/ le-dispositif-du-medecin-traitant.php. Chevreul, K., I. Durand-Zaleski, S. Bahrami, C. Hernández-Quevedo, and P. Mladovsky (2010). “France: Health System Review,” Health Systems in Transition 12(6):1–291. CISS (2014). Exercice libéral des médecins. http://www.leciss.org/sites/default/files/44-Exercice%20liberal%20medecinefiche-CISS.pdf. Cour des Comptes (2013). Le médecin traitant et le parcours de soins coordonnés : une réforme inaboutie. https://www. google.fr/url?url=https://www.ccomptes.fr/content/download/53083/1415030/version/2/file/2_1_3_medecin_traitant_ parcours_soins_coordonnes.pdf&rct=j&frm=1&q=&esrc=s&sa=U&ved=0CD0QFjAHahUKEwit3JHY4qXHAhXpK9sKHV1eByc &usg=AFQjCNHnPSaxT0EnmwuvCpwR37kbWQJlIw. Cour des Comptes (2014). Les relations conventionnelles entre l’assurance maladie et les professions libérales de santé. http://www.ccomptes.fr/Actualites/Archives/Les-relations-conventionnelles-entre-l-assurance-maladie-et-les-professionsliberales-de-sante. DREES (2014). Ministère de la Santé. Comptes nationaux de la santé 2013. http://www.drees.sante.gouv.fr/IMG/pdf/ comptes_sante_2013_edition_2014.pdf. DREES (2015). Ministère de la Santé. Les dépenses de santé en 2014. http://www.drees.sante.gouv.fr/IMG/pdf/rapport_ cns_2015_commission.pdf. Fonds CMU 2014. Sixieme rapport d’evaluation de la loi du 27 juillet 1999 portant creation d’une couverture maladie universelle. http://www.cmu.fr/fichier-utilisateur/fichiers/Rapport_Evaluation_VI.pdf. INSEE 2015. Médecins suivant le statut et la spécialité en 2015. http://www.insee.fr/fr/themes/tableau. asp?reg_id=0&ref_id=NATTEF06102 INSEE 2015;2. Les revenus d’activité des médecins libéraux récemment installés : évolutions récentes et contrastes avec leurs aînés. http://www.insee.fr/fr/ffc/docs_ffc/REVAIND15_c_D2_sante.pdf. IRDES 2013. http://www.irdes.fr/Publications/Qes2013/Qes186.pdf. IRDES 2014. http://www.irdes.fr/recherche/questions-d-economie-de-la-sante/201-les-formes-du-regroupementpluriprofessionnel-en-soins-de-premiers-recours.pdf. Ministère de la Santé 2013(1). http://www.social-sante.gouv.fr/IMG/pdf/01_Rapport_activite_liberale_EPS-2.pdf. Ministère de la Santé 2013(2). http://www.social-sante.gouv.fr/IMG/pdf/rapport_final_annexes.pdf. International Profiles of Health Care Systems, 2015 67
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
Page 15 and 16: AUSTRALIA In 2013, the federal gove
Page 17 and 18: What is being done to reduce dispar
Page 19: References AUSTRALIA Australian Bur
Page 22 and 23: CANADA What is covered? Services: T
Page 24 and 25: CANADA funding to 145 not-for-profi
Page 26 and 27: CANADA Organization of the Health S
Page 28 and 29: CANADA provides recommendations to
Page 30 and 31: CANADA Health Council of Canada (20
Page 32 and 33: CHINA Private health insurance: Com
Page 34 and 35: CHINA is not substantially more exp
Page 36 and 37: CHINA Organization of the Health Sy
Page 38 and 39: CHINA References Chen, X. (2014).
Page 40 and 41: DENMARK In addition, nearly 1.5 mil
Page 42 and 43: DENMARK Social psychiatry and care
Page 44 and 45: DENMARK Quality data for a number o
Page 46 and 47: DENMARK portion is small, it makes
Page 48 and 49: 48
Page 50 and 51: ENGLAND immunization, and vaccinati
Page 52 and 53: ENGLAND Hospitals: Publicly owned h
Page 54 and 55: ENGLAND Organization of the Health
Page 56 and 57: ENGLAND How are costs contained? Ra
Page 58 and 59: ENGLAND Organisation for Economic C
Page 60 and 61: FRANCE VHI finances 13.8 percent of
Page 62 and 63: FRANCE The average income of primar
Page 64 and 65: FRANCE What are the key entities fo
Page 68 and 69: FRANCE Nolte, E., C. Knai, and M. M
Page 70 and 71: GERMANY There were 42 substitutive
Page 72 and 73: GERMANY The 16 state governments de
Page 74 and 75: GERMANY management system, by the s
Page 76 and 77: GERMANY What major innovations and
Page 78 and 79: INDIA Private health insurance: The
Page 80 and 81: INDIA provide after-hour care, reim
Page 82 and 83: INDIA are provided by other ministr
Page 84 and 85: INDIA How are costs contained? Ther
Page 86 and 87: 86
Page 88 and 89: ISRAEL Together, these two types of
Page 90 and 91: ISRAEL Primary care physicians are
Page 92 and 93: ISRAEL Organization of the Health S
Page 94 and 95: ISRAEL • Using electronic health
Page 96 and 97: 96
Page 98 and 99: ITALY during hospitalization (Thoms
Page 100 and 101: ITALY Some regions are promoting ca
Page 102 and 103: ITALY Organization of the Health Sy
Page 104 and 105: ITALY although the degree of evolut
Page 106 and 107: ITALY The author would like to ackn
Page 108 and 109: JAPAN What is covered? Services: Al
Page 110 and 111: JAPAN incentives for providers to c
Page 112 and 113: JAPAN Organization of the Health Sy
Page 114 and 115: JAPAN The author would like to ackn
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THE NETHERLANDS receive faster acce
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THE NETHERLANDS Hospital payment ra
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THE NETHERLANDS Organization of the
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THE NETHERLANDS References Organisa
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NEW ZEALAND provided in GP clinics.
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NEW ZEALAND management (e.g., clean
Page 128 and 129:
NEW ZEALAND including such informat
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NEW ZEALAND largely through efficie
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132
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NORWAY Primary, preventive, and nur
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NORWAY Patients are free to choose
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NORWAY What are the major strategie
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NORWAY The National System for the
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142
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SINGAPORE Medifund is the governmen
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SINGAPORE Public hospital funding i
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SINGAPORE Public consultation: The
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SINGAPORE To keep demand for servic
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152
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SWEDEN What is covered? Services: T
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SWEDEN Hospitals: There are seven u
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SWEDEN Care, which promotes use of
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SWEDEN What major innovations and r
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SWITZERLAND Insurers offer premiums
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SWITZERLAND Hospitals: About 70 per
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SWITZERLAND Organization of the Hea
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SWITZERLAND To control pharmaceutic
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170
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UNITED STATES What is covered? Serv
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UNITED STATES Administrative mechan
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UNITED STATES The Institute of Medi
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UNITED STATES adopted at least a ba
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The COMMONWEALTH FUND Affordable, q
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