France

126
Health systems in transition
France
(INCa, 2014). However, the HAS recommends opportunistic screening because
of the difficulties in targeting the populations of women who have not adhered
to the recommended screening regimen (HAS, 2013).
Public health programmes in France are often targeted either by population
(PMI services for women and children) or by disease (mass screening
programmes for breast cancer and colorectal cancer). Providing such services
free reduces financial barriers to access but does not ensure participation.
Breast cancer and colorectal cancer together account for 16% of cancer deaths
in France (Table 1.4), underscoring the need for efforts to ensure early diagnosis
and treatment. In 2012, participation in the mass breast cancer-screening
programme was just over 50%, lower than the 70% participation rate considered
the minimum acceptable level according to European guidelines. Nonetheless,
30% of the breast cancer cases in France each year were detected through the
screening programme (INCa, 2013). Participation in the mass colorectal cancer
screening programme was even lower (30%), and a study of factors influencing
patient participation recommended actions targeted at patients under 60 years,
men and individuals living in deprived areas (Le Breton et al., 2012).
5.2 Patient pathways
This section describes a typical patient pathway for a patient needing
a hip replacement.
In France, a 70 year-old woman requiring a hip replacement due to arthritis
would typically first visit her GP, who would prescribe radiography of the hip
in order to confirm the diagnosis. The radiograph would typically be performed
in a private ambulatory radiology practice but could also be performed as an
outpatient examination in a hospital. The GP would then send the patient to an
orthopaedic surgeon working either in the public or in the private sector. Both
visits would be covered by SHI with a co-insurance rate of 30%, most often
covered by VHI.
Alternatively, the patient could visit an orthopaedic surgeon directly, thus
bypassing the gatekeeping procedure. For a surgeon who follows the Sector 1
agreement (see section 3.7.2), the co-insurance rate would then be increased
from 30% to 70% (see section 3.3.1), and the surgeon would be allowed to
charge up to €8 on top of the official tariff, both leading to a maximum overall
increase of €18 in the patient’s OOP expenditures. That additional expense
would not be covered by the patient’s VHI, since insurers have strong financial
incentives not to cover these fees.