The French health care system

2021
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Under the French health care system, care is provided at various types of facilities: private practices for non-hospital care, healthcare facilities for hospital-based care, health and social, and residential facilities for “vulnerable” elderly or disabled customers. It is grounded in the patient's and resident's freedom of choice: each patient is free to choose his/her primary care physician (“médecin traitant”), direct-access specialist, health care facility, or residential facility, either in the public or the private sector.

France's public health insurance system “L'Assurance Maladie” covers the following types of care if they appear on the official list of reimbursable care:

I. How the French health care system is administered by public policy

a) At the national level: the ministries

The State directly finances and organizes the delivery of health and health and social services. This means that the ministers in charge of health and solidarity, public accounts, and civil service, have a wide range of responsibilities including:

France's Ministry of Health is principally tasked with:

In addition, inspection authorities such as France's Court of Auditors (“Cour des Comptes”) or the General Inspectorate of Social Affairs (“Inspection Générale des Affaires Sociales”) check that the social security financing law is properly executed.

b) At the regional level: France's Regional Health Agencies

France's Regional Health Agencies (“Agences regionales de santé”/ ARS) coordinate prevention and health and supportive care. They ensure that resources are managed in a consistent manner to ensure that all patients have equal access to safe, continuous, high-quality care. On this account, they have the following responsibilities:

As seen above, each ARS takes France's nationwide policies and adapts them to the
(population-related, epidemiological, or geographical) characteristics of its region by
drawing up regional health programs (“programmes régionaux de santé”/ PRS) which
comprise:

Combating inequality, improving equal access to health care and health and social services throughout the region, and better adjusting solutions to specific local characteristics and local needs constitute the objectives of these regional services.

c) France's State agencies or public organizations

-The French biomedicine agency is a State-run national agency created by France's bioethics law. The Agency's scope covers organ, tissue, and cell retrieval and transplants, along with human reproduction, embryology, and genetics. It is France's top authority on all medical, scientific, and ethical issues in these areas.

It is tasked with:

-France's national blood authority EFS: EFS is France's single public blood transfusion authority. It is mainly tasked with ensuring that France is self-sufficient in sourcing blood products. It is also involved in a wide range of activities such as medical biology analyses (conducting various types of biological, hematological, and immunological analyses, tests which are essential both for a transfusion and for an organ, tissue, or cell transplant), cell and tissue therapy, or research (in emerging fields such as cell and tissue engineering, immunologic donor-recipient pairing, or the development of new microbiological risk detection and prevention technologies).

d) Health insurance schemes

detailed in section IV.

e) Medical associations and unions

France has medical associations for seven categories of health care professionals: physicians, pharmacists, midwives, dental surgeons, nurses, massage and physical therapists, and chiropodistspodiatrists (https://www.leclio.fr/categorie-ordre/ordres-desprofessions-de-sante/). These associations are professional corporations instituted by French law. They both represent the profession and provide a public service by helping to regulate it and serving as a disciplinary authority for members. Association membership is mandatory for members of these professions to be able to practice.

Indeed, these medical associations are private corporate entities tasked with providing a public service. They play a double role:

In order to perform the public service with which they are tasked, the associations are vested with two public powers:

The unions are in charge of negotiations between health care professionals and the French health insurance system with regard to fees and all issues related to medical practice.

f) Health care system users, by way of patients' organizations

They are among the qualified members participating in the health care facilities' oversight committee. The role of this committee is focused on strategy and on the ongoing oversight of the facilities' management. Patients' organizations that are legally declared and focus on health and patient care quality can receive accreditation on the basis of the organization's actual, public work to defend the rights of patients and users of the health care system, as well as the training and information programs it conducts.

II. How care is organized

a) Public health

At national level, “Santé publique France” is an authoritative public health agency that provides scientific expertise with State oversight. It is tasked with improving and protecting the health of the population with a particular focus on three major areas:

As a public agency providing scientific health expertise, Santé publique France is in charge of the following:

At municipal level, national public health directives are rolled out by prevention-based organizations such as:

France's municipalities are legally responsible for monitoring and purifying the water supply, keeping air and noise pollution down, providing sanitation services, protecting the population from exposure to radiation, and for housing, food, and industrial hygiene.

b) Non-hospital-based care

- Health care providers and producers of health-related goods and services. This includes:

The health care professionals who work at these facilities mainly provide primary and preventive care. They are required to draw up a health charter that shows how they work together to provide care. Residential care facilities are required to sign a multi-year performance and means contract with the regional health agency (“Agence régionale de santé”/ ARS) before they can receive any funding from that agency.

France's coordinated healthcare pathway system ("parcours de soins coordonnés") requires each French-insured individual over age 16 to designate and register a primary care physician ("médecin traitant") with their local health insurance fund. The primary care physician acts as the gatekeeper for access to care. They are the patient's first stop on the care pathway and refer the patient to other healthcare professionals (specialist or hospital-based physicians, etc.) if necessary. The primary care physician coordinates all of the patient's care and centralizes all information on the care the patient receives and their state of health by managing their medical file.

Patients are free to choose their primary care physician ("médecin traitant") This role can be filled by a general practitioner or specialist physician practicing anywhere in France, and the patient can change primary care physicians at any time. If the patient does not follow the coordinated healthcare pathway and sees a specialist without first consulting their primary care physician, this specialist appointment will be reimbursed by the French health care system ("l'Assurance maladie") at a lower rate.

c) Hospital-based care

Health care facilities offer different types of services (hospital-based or health and social). These can be either public or private:

- hospitals can belong to one of several categories: public facilities, chartered private non-profit facilities (such as private hospitals or cancer treatment or dialysis centers) and private for-profit facilities. They provide general care (medicine, surgery, obstetrics) and/or more specialized care (psychiatry and mental health) through the diagnosis, monitoring, and treatment of patients with illnesses or injuries as well as pregnant women;

- France's regional hospital groups (“Groupements hospitaliers de territoires”/ GHT) are a contract-based program, which became compulsory in 2016, among each region's public health care facilities, by which they agree to coordinate to form a strategy based on shared, proportionalized care for each patient that is documented through a shared medical charter.

The idea is to encourage each region's health care facilities to pool their medical teams and share out their activities to ensure that each facility has a well-defined role to play in the region. GHTs organize how the facilities complement one another by taking account of each facility's unique characteristics and what it contributes to the delivery of care. They are a way to improve how care is organized in each region and to draw up a medical charter that is in line with the population's needs.

d) Emergency care

Hospitals' on-site emergency medical response teams (SAMU) and 24-hour care providers administer emergency pre-hospital care. Emergency medical response teams can be contacted by dialing the free nationwide emergency number, 15, from any phone, anywhere in France. When a call is placed, the information is shared with the emergency police (17) and fire (18) call centers to ensure that medical emergencies are handled appropriately. France's medical and fire call centers also respond to calls to the European emergency number 112.

Emergency calls which are placed to the medical call center are handled by specialized receptionists with physician supervision and support. Whatever measures are taken are determined by level of urgency. If emergency care is needed on-site, the medical emergency call centers can send a mobile emergency and resuscitation team (“SMUR”), a fire rescue first response team, or an on-call general practitioner. Otherwise, if necessary, the patient is advised to take an ambulance to the nearest hospital emergency room. The “continuity of care” system is designed to deal quickly and appropriately with patients' needs which arise at night or on weekends or holidays when non-hospital medical facilities are closed.

e) Long-term care

- Health and social care facilities include residential facilities for dependent elderly people (“établissements d'hébergement pour personnes âgées dépendantes”/ EHPAD) as well as facilities for people with disabilities.

They are designed to provide support and care for “vulnerable” individuals experiencing financial insecurity, social exclusion, disability, or dependency. The public and social services they provide are as follows:

- residential or temporary eldercare: this is offered by numerous providers with varying levels of care. These include independent-living facilities (“foyers logements”) which offer a range of non-medical services (such as meals and laundry) but basically no medical care, retirement homes (residential facilities for dependent elderly people (“établissements d'hébergement pour personnes âgées dépendantes”/ EHPAD), which house elderly residents and also offer medical care, long-term assisted-living units which care for heavily dependent patients with severe illnesses requiring constant medical monitoring, and intermediate services which provide short-term care for medically fragile elderly patients who are not housed in a residential facility. Care can be provided on a daily basis (day care) or for a temporary period (temporary care).

Residential facilities for medically fragile elderly individuals are currently financed in part by the French health insurance system, which covers the cost of medical care, in part by the local-level “conseils généraux,” which cover personal expenses related to the loss of independence, and finally by the residents themselves, who mainly cover their own room and board.

- in-home care: intermediate-level care providers bring temporary care to dependent patients as well as respite services for their caregivers. This type of care increases engagement and self-sufficiency for dependent individuals. French health insurance -financed in-home care is mainly provided by independent doctors and nurses and, to a lesser extent, by in-home nursing care providers (“services de soins infirmiers à domicile”/ SSIAD), which provide non-medical (hygiene) and medical (bandaging, distributing medications, injections) nursing care. In-home service providers (“services d'aide et d'accompagnement à domicile”/ SAAD), which are offered through France's social welfare programs, cover household help and other in-home services to aid with ordinary and instrumental activities of daily living (home maintenance, laundry, meal preparation, self-care, and help with dressing and undressing).

f) Pharmacies

The French pharmaceutical market has three different components: prescription-only and prescribable drugs, which are both mainly dispensed by retail pharmacies, and hospital-only drugs.

The drug distribution chain is highly regulated for wholesalers and pharmacies alike. Full-line wholesalers have “public service” status and are subject to regulatory oversight by the French National Agency for medicine and health product safety (ANSM) with regard to the range of drugs supplied, inventory levels, delivery times to specific local areas, and their profit margins. Pharmacies hold a monopoly on the distribution of drugs dispensed on the basis of a medical prescription. In general, retail pharmacies are required to belong to a qualified pharmacist or a group of pharmacists partnering to form a company: these pharmacists or companies cannot be the owners of more than one pharmacy. The State sets an official maximum number of pharmacies, determined both by the size of the population being served and the distance to the nearest pharmacy. Pharmacists receive financial incentives to dispense generic drugs.

Direct-to-consumer drug advertising is subject to prior authorization and restricted to products that meet three requirements: they must be able to be dispensed without a doctor's prescription, they must not be covered by the French health insurance system, and no restriction on advertising can have been included in the product's marketing authorization. Vaccines are the only exception to this rule.

Over-the-counter drugs can be sold online but only by pharmacists, who must be working directly through a brick-and-mortar pharmacy and have authorization from their regional health agency (“ARS”) to conduct online sales.

Doctors, dentists, midwives, and pharmacists are required to report any adverse events associated with a medication to their regional drug safety center (“centre régional de pharmacovigilance”), which will then conduct the necessary investigations and notify the manufacturer. Patients and patient organizations can report any adverse events directly. Approved adverse event reports must be submitted to the European Medicines agency within 2 weeks.

III. How to contact a French health care provider

IV) How the health care system is financed

In France, the financing of the health care reimbursement system is organized into two main levels: compulsory health insurance schemes and supplementary health insurance schemes.

a) France's compulsory basic health insurance schemes

They are characterized by compulsory membership and contributions. This means that they are dependent on widespread solidarity on the basis of income-proportional contributions, and access to care that is determined in accordance with needs.

The main social security schemes (the general scheme, which has incorporated self-employed workers as from 01/01/2018, plus the agricultural scheme, are grouped together within the National health insurance fund Union (“Union nationale des caisses d'assurance maladie”/ UNCAM), the role of which is to:

France's compulsory health insurance schemes focus heavily on “major risks,” i.e. the health risks that have the greatest impact on members' income, either because their conditions require long-term and/or costly care, or because they require extensive use of expertise and technology, both in terms of equipment, techniques, and staff, and in terms of hospital-based expenses.

b) The supplementary schemes (mutual funds, insurance companies, and providence funds)

These supplementary schemes are dependent on solidarity that is limited to members. They offer rates of coverage that vary depending on the member's type of policy. They are used to pay the share of the member's health care expenses that is not covered by the compulsory basic scheme (“tickets modérateurs” (co-payments), “franchises” (flat out-of-pocket charges), “forfaits hospitaliers” (daily hospital charges), coverage for opticals, orthotics, equipment, etc.).

If customers do not have supplementary group coverage through their employment, they can take out supplementary insurance from a mutual fund, a providence fund, or an insurance company.

c) Public financing sources (the State)

They are mainly used for prevention and medical and pharmaceutical research, training for health professionals (doctors, dentists, pharmacists, and qualified medical workers), supplementary universal health coverage (“couverture maladie universelle complémentaire”/ CMU-C), endowments for military hospitals, emergency medical care, and benefits awarded to those covered by State medical aid (“aide médicale d'Etat”/ AME);

d) French households

Finally, a share of the expenses may be paid out-of-pocket by the patient.

V) What type of oversight is conducted for health care professionals?

a) France's regional health agencies

for risk-prevention purposes, France's regional health agencies (ARS) have broad inspection-verification powers in three areas: health safety, how facilities and services are run, and medical procedures and practices.

Inspection-verifications are conducted in the following areas:

The goal is to conduct inspection-verifications that coincide with France's national health policies.

- Health safety

This pertains to all risks connected to health care work, to products consumed (food and health products) and to living environments (water, air, and soil).

The inspection-verifications conducted by the agencies focus on:

- How France's health and health and social care facilities are run

France's regional health agencies (ARS) ensure that health and health and social care facilities and services are run smoothly in terms of: staff, on-call medical services, staff qualifications, etc.

- Medical procedures and professional practices

In partnership with the French health insurance authority (“Assurance maladie”) and/or the relevant medical Associations, the regional agencies conduct inspection and awareness-raising programs for health care professionals on the following topics related to the safety, quality, and appropriateness of care:

b) The French National Authority for Health (“Haute Autorité de Santé”/ HAS)

The HAS accredits doctors to practice at France's health care facilities. On this account, the HAS is in charge of the following:

With a view to the continuous improvement of the quality and safety of care, all of France's public and private health care facilities are required to undergo an outside evaluation process known as certification.

This process, which is conducted by the French National Authority for Health (“Haute Autorité de Santé”/ HAS), is designed to provide an independent assessment of the quality of a facility, or in other cases, of one or more of a facility's internal units, setups, or activities, through the use of indicators, criteria, and standards pertaining to the procedures, best clinical practices, and results of the facility's various wards and activities.

c) The French national agency for medicines and health products safety (ANSM)

ANSM is the decision-making authority over health product safety, from manufacture to sale. It has four major responsibilities:

ANSM has decision-making authority over medicines (all medicines (before and after marketing authorization) and raw materials, blood-derived medications, narcotics and psychotropic substances, vaccines, homeopathic products, both plant-based and pharmaceutical preparations, pharmacy and hospital formulations), biological products (organs, tissue, cells for therapeutic use, cellular and gene therapy products, labile blood products and ancillary therapeutic products), medical devices (therapeutic, diagnostic, in vitro diagnostic, and in technical facilities and medical software programs), cosmetic and tattoo products and other health products (biocides).

ANSM performs a number of activities in France and on behalf of the European Union:

These actions give rise to health policy decisions which are taken on behalf of the French State:

ANSM also advances information for patients, health care professionals, professional contact persons and scholarly associations, and the press.

d) The French Agency for Food, Environmental and Occupational Health & Safety (ANSES)

ANSES assesses food, environmental, and workplace risks through its surveillance, early-warning, research, and investigation programs. Its monitoring, vigilance and surveillance work provides input for risk assessment. This means that ANSES fully addresses all types of risks (chemical, biological, physical, etc.) to which a person may be subjected, intentionally or otherwise, at all ages and stages of life, including through exposure at work, while travelling, while engaging in leisure activities, or via their diet. ANSES also assesses the effectiveness and risks of veterinary medicinal products, plant protection products, fertilizers, growing media and their adjuvants, as well as biocides, with a view to delivering marketing authorizations.  It also provides assessments of chemicals.

ANSES is also in charge of occupational safety oversight nationwide and is responsible for preventing and protecting worker health. 

e) France's Institute for Radiological Protection and Nuclear Safety (IRSN)

IRSN's field of expertise covers all risks linked to ionizing radiation used in industry or for medicine, as well as naturally occurring radiation. IRSN contributes to radiation protection training directed at health sector professionals and workers exposed to occupational hazards. It contributes to round-the-clock health surveillance in radiation protection by monitoring environmental radiation, as well as managing and processing dosimetric data for workers exposed to ionizing radiation. IRSN also manages the national inventory of radioactive sources.