France

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Health systems in transition
France
All professionals are subject to the terms of the agreement unless they
expressly opt out. In exchange, SHI pays a part of the professionals’ social
security contributions. These agreements govern health professionals’ relations
with patients who have public coverage and with SHI. The method of payment
and the amount health professionals receive, therefore, should conform to the
terms of these agreements or to the minimum contractual regulations that the
government sets out in the absence of an accepted agreement. Agreements
for each profession cover a period of four or five years or extend until a new
agreement is signed. However, there are regular amendments (at least annual
for doctors) that take into account changes following the yearly Social Security
Finance Act and other new measures. The Ministry in charge of Health plays
a significant role in the negotiation. Negotiations between SHI (UNCAM)
and doctors tend to be very difficult because of the power of the medical
professionals’ associations, with SHI rarely managing to implement the full
range of measures it seeks.
In recent years, conventions have included several types of measure to
promote quality and efficiency in the health system. P4P based on public
health objectives was included in the 2011 collective bargaining agreement
with physicians (see sections 2.8.3 and 3.7.2). Interestingly, the 2007 nurses’
agreement was used as a means of introducing controls on the geographical
distribution of health professionals for the first time (other than pharmacists,
for whom distribution has long been regulated). However, it was not followed
by similar measures for other health professionals, in particular doctors (see
section 6.1.3).
Purchasing relations with hospitals differ. The Ministry in charge of Health
is responsible for public and private hospitals and sets the DRG tariffs. SHI
reimburses hospitals on a case-payment basis in public hospitals, private
non-profit-making hospitals and profit-making hospitals with a SHI agreement
(cliniques conventionnées). For the very few private profit-making hospitals
with no SHI agreement (cliniques non conventionnées), patients pay for their
care directly and are reimbursed based on specific statutory tariffs called tariffs
without consultation (tarif d’autorité), which are very low and have not been
increased since the 1960s.