Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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188 Special Solidarity Fund KCE Reports 133 9.14.2.2 What is covered? The public health insurance scheme covers hospital care, ambulatory care, prescription drugs, as well as minimal coverage of outpatient eye and dental care. Cost-sharing: The principle of cost-sharing, or ticket modérateur, is extensively applied to public-financed health services in France. There are three forms of cost-sharing: coinsurance, co-payments and extra billing. Co-insurance rates are applied to all health services and drugs listed in the publiclyfinanced benefits package and vary depending on: • type of care: hospital care (20% plus a daily co-payment of €16), GP visits (30%), dental care (30%); • type of patient: e.g. patients suffering from chronic diseases and low income patients are exempt from cost sharing; • effectiveness of the prescription drug: 0% for highly effective drugs, 35%, 65% or 100% for drugs with a limited therapeutic value; • level of compliance with the current gate keeping system (médecin référent): co-insurance regulation tends to favour visits to people’s ‘médecin référent’ (30% co-insurance rate) to visits to other GPs (50%). As mentioned, treatment costs are split between public health insurance (what the state pays) and the patient (co-payment). However, payments by patients can be reimbursed by complementary private health insurance, up to 100%. From 2008, some smaller copayments ceased being eligible for reimbursement up to an annual ceiling of €50. Reimbursement by the publicly financed health insurance scheme is based on a reference price (tarif de convention). Although a patient may be treated by a practitioner classed as ‘conventioné’, he can ask more than the tariff de convention provided it is "reasonable and tactful" to do so. For example, a specialist who has extra qualifications or experience in other countries could charge extra for its services. This supplementary charge is called a ‘depassement’ or extra billing. The difference between the extra billed amount and the reference price is not covered by public health insurance, nor complementary private health insurance and is fully charged to the patient. Safety nets: France introduced some safety nets for people with invalidity or with work injury, people with specific chronic illnesses and low income patients. These groups of citizens are exempt from co-insurance regulations and are reimbursed at 100% of the “tarif de convention” if one of the following applies: • A patient suffers from one or more of the 30 chronic or acute medical conditions that are listed, including insulin-dependent diabetes, cancer and heart disease; • A patient requires long-term care or care for a long-standing condition (called an ALD–affectation de longue durée); • A patient is hospitalised beyond 30 days. From the 31st day hospital stays are 100% reimbursable; • A patient’s surgery costs are above €91. Children and low income residents are exempt from paying non-reimbursable copayments. Complementary private health insurance (police complémentaire), by most of the patients obtained through their employer, covers patients’ statutory cost-sharing, meaning the share of health care costs that is not reimbursed by the public health insurance scheme. However, this is only the case for health services and prescription drugs that are part of the publicly-financed benefit package. Low income residents (for example, €10,768 for a couple) that cannot afford a police complémentaire could rely on free complementary state-funded healthcare, called CMU complémentaire. They cannot be extra billed by doctors.
KCE Reports 133 Special Solidarity Fund 189 Financing of the health system: The public health insurance scheme is financed by employer and employee payroll taxes (43%); a national income tax (contribution sociale generalisée); created in 1990 to broaden the revenue base for social security; revenue from taxes levied on tobacco and alcohol (8%); state subsidies (2%); and transfers from other branches of social security (8%). 9.14.3 The organization of healthcare provision In comparison to the situation in the Netherlands, the Government has an important and steering role in the management of healthcare system in France. Sometimes, it intervenes directly in the production and financing van healthcare services. Moreover, it strongly supervises the interactions between healthcare providers, patients and health insurers. Every year the French parliament sets a maximum limit for the rate of expenditure growth in the public health insurance scheme for the following year. Health insurers have a public character and are managed by a board of representatives, with equal representation from employers and employees. Public health insurance funds are statutory entities and their membership is based on occupation. Hence, there is no competition between them. There is no system of risk adjustment among them like it is the case in the Netherlands, even though there is inadvertent risk selection based on occupation. It should be noted that there is limited competition among mutual associations providing complementary private health insurance. Physicians are self-employed and paid on a fee-for-service basis. The cost per visit is slightly higher for specialists (€23) than for GPs (€22) and is based on negotiation between the government, the public insurance scheme and the medical unions. Depending on the total duration of their medical studies, physicians may charge above this level. The 2004 reform of health financing in France introduced a voluntary gate keeping system for adults, known as “médecin traitant”. However voluntary, there are strong financial incentives favouring visits to the referent GP. Two-thirds of hospital beds are in government-owned or not-for profit hospitals. The remainder is private for-profit. All university hospitals are public. Hospital physicians in public or not-for profit facilities are salaried. Public hospitals are currently financed by a general budget that also includes all medicines that are used within the hospital. Some expensive and innovative medicines are financed by special financial resources that are accorded by the Minister of Health. Private hospitals are financed on the basis of a day-price, covering costs of stay and nursing, and of a flat-premium covering expenditure for medicines. Compared to public hospitals, honoraries are charged separately. From 2008, all hospitals and clinics will be reimbursed via the DRG-like prospective payment system, like it is the case in the Netherlands. Public and not-for-profit hospitals benefit from additional non activitybased grants to compensate them for research and teaching and other additional services. As mentioned, interactions between the social security system and the healthcare providers are based on conventions, setting out the framework for compensations and reimbursements. Conventions are the product of negotiations between the representative employees’ organisations and representatives of the important public health insurance schemes. Based on these conventions, healthcare providers charge their delivered services in function of two elements: the classification (nomenclature) of groups of services based on their nature, and the negotiated price for these different service groups. The Nomenclature lists also all medicines that are reimbursed by public health insurance to the patient.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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