JANUARY

FRANCE
The average income of primary care doctors in 2011 was EUR82,020 (USD98,925), 94 percent of which came
from fees (INSEE 2015) and the remainder from financial incentives and salary. Fees, set by the Ministry of
Health and SHI, have been frozen since 2011 (Cour des Comptes 2013).
Experimental GP networks providing chronic care coordination, psychological services, dietician services, and
other care not covered by SHI are financed by earmarked funds from the Regional Health Agencies (Nolte,
2008).
Outpatient specialist care: About 36 percent of outpatient specialist care providers are exclusively selfemployed
and paid on a fee-for-service basis; the rest are either fully salaried by hospitals or have a mix of
income. In October 2014, participation in pay-for-performance programs was extended to all self-employed
physicians, including specialists, who must meet disease-specific quality targets in addition to those targets that
apply to GPs. The average income derived from pay-for-performance is EUR5,480 (USD6,609) per physician
(Cour des Comptes 2014); such income constitutes less than 2 percent of total funding for outpatient services.
Patients can choose among specialists upon referral by a GP, with the exception of gynecology, ophthalmology,
psychiatry, and stomatology (Assurance Maladie, 2015). Bypassing referral results in reduced SHI coverage.
The specialist fee, set by SHI, is EUR28 (USD34), but specialists can balance-bill. Half of specialists are in group
practices, which are increasing among specialties that require major investments, such as nuclear medicine,
radiotherapy, pathology, and digestive surgery (Sénat, 2014).
Specialists working in public hospitals may see private-pay patients, on an outpatient or an inpatient basis, but
they must pay a percentage of their fees to the hospital. A 2013 report to the Ministry of Health estimated that
10 percent of the 46,000 hospital specialists in surgery, radiology, cardiology, and obstetrics had treated private
patients. The mounting discontent over excessive balance billing revealed in the press, together with the claim
of unfair competition made by private clinics, has prompted several public inquiries—the latest of which
resulted in recommendations to increase public control over this activity (Ministère de la Santé 2013).
Administrative mechanisms for paying primary care doctors and specialists: Patients pay the full fee
(reimbursable portion and balance billing, if any) and claim reimbursement covering the full sum or less,
depending on coverage, minus EUR1.00 (USD1.20), capped at a maximum of EUR50 (USD60) per patient per
year. The 2015 Health Law included a contentious item stipulating that by 2017 patients will pay directly only
for balance billing, and the reimbursable fee will be paid directly by SHI.
After-hours care: After-hours care is delivered by the emergency departments of public hospitals, private
hospitals that have signed an agreement with their Regional Health Agency, self-employed physicians who work
for emergency services, and, more recently, public facilities financed by SHI and staffed by health professionals
on a voluntary basis. Primary care physicians are not mandated to provide after-hours care.
Physicians are paid an hourly rate, regardless of the number of patients seen. Emergency services can be
accessed via the national emergency phone number, which is staffed by trained professionals who determine
the type of response needed. Feasibility of telephone or telemedicine advice is currently under assessment; it
would include sharing information from the patient’s electronic medical record with the patient’s primary care
doctor. Publicly funded multidisciplinary health centers with self-employed health professionals (physicians and
nonphysicians) allow better after-hours access to care in addition to more comprehensive care; fee-for-service
payment is the rule for these centers (IRDES, 2014).
Hospitals: Public institutions account for about two-thirds of hospital capacity and activity, private for-profit
facilities account for another 25 percent, and private nonprofit facilities, the main providers of cancer treatment,
make up the remainder (DREES, 2015). Since 2008, all hospitals and clinics are reimbursed via the diagnosisrelated
group (DRG) system, which applies to all inpatient and outpatient admissions and covers physicians’
salaries. Bundled payment by episode of care does not exist.
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The Commonwealth Fund