Chapter 2

and/or increase the contributions. Through time, the rate of reimbursement of services
has decreased, a daily lump sum per day of hospitalization has been imposed. In the
close past, such decisions were taken merely on the basis of financial emergency.
Symmetrically, contributions of insures have increased, either through higher wage taxes
or through the increase of the rate of the CSG tax. French citizens also pay a yearly 0,5%
contribution on their incomes to reimburse the social debt.
Other contributors have been the private office-based physicians. Fees for service of private
physicians are regulated in France, and through the negotiation of the fee schedule,
public authorities have tried to maintain the prices through time. The facial fees have
actually increased slowly, but there have been many ways for physicians to avoid the
effects of price control. First, there is no volume control on practice. Second, since 1980,
French private practitioners may charge more than the official fee-schedule. Thus,
patients face higher co-payments, which they partially compensate through complementary
insurance. As a counterpart, the Sickness Fund does not contribute to their pension
plans anymore. The medical profession is also able to organize strong collective
actions to obtain higher fees. In 2001-2002, general practitioners deliberately and massively
overcharged their visits (from € 17 to € 20), and the government finally gave in and
accepted this price increase. Since the end of the eighties, successive governments and
the sickness fund have tried to obtain counterpart of price increases, like moderation of
prescriptions (French people have the world record in terms of drug expenditure per
capita, € 500 in 2005), and compliance to good practice guidelines, with a variable success
through time. Recent successes are the moderation of the prescription of antibiotics,
through an intensive information campaign on the risk of developing bacterial resistance,
and the prescription of generics, although the battle is not yet completely won.
Finally, the drug industry is also a regular target of public authorities. Drug expenditures
are submitted to an annual cap, voted by the parliament. To reach this objective, public
authorities have invented a complex set of regulations which mixes macro-economic
constraints and micro-economic agreements with companies, based on price-volume
adjustments and discounts, plus conjunctural taxes when expenditures grow too fast.
In the more recent period, co-payment has been presented as a virtuous incentive, to
make insures more cost sensitive (to control moral hazard), or as an improvement in the
efficiency of the sickness fund. For example, in the past 5 years, the government has
decided to stop reimbursing (or to decrease the level of reimbursement of) drugs that are
considered as bringing a marginal health benefit. In August 2004, an important reform
has been voted, which was presented as a major reorganization of primary care services.
Indeed, the law implemented a form of gatekeeping. Every insure is supposed to sign in
with one general practitioner, the “médecin traitant”, who has the responsibility to refer
him/her to specialist care. Insures who do not comply and visit directly a specialist will
have a lower rate of reimbursement. GPs also get an annual lump sum to take care of
chronic so-called ALD patients, who are covered 100%. As a counterpart, they agree to
follow specific evidence-based guidelines for such patients. Moreover, for each visit to a
private physician, a € 1 contribution is paid by the patient. Specialists have been allowed
to increase their basic fee for patients who are referred by a GP, and most observers sug-
[123]
CEIS Health Report 2006