Health Care Reform in France — The Birth of State-Led Managed Care
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《新英格兰医药杂志》
The World Health Organization recently ranked the French health care system the best in the world.1 Although the methods and data on which this assessment was based have been criticized, there are good grounds for being impressed by the French system. Yet in August 2004, with the national health insurance (NHI) system facing a severe financial crisis, France enacted Minister of Health Philippe Douste-Blazy's reform plan. Like previous efforts at health care reform, this one seeks to preserve a system of comprehensive benefits, which is supported by the major stakeholders.
(Figure)
H?tel Dieu Hospital, Paris, Early 19th Century.
Image: Wellcome Library, London.
French policymakers typically view their NHI system as a realistic compromise between Britain's National Health Service, which they believe requires too much rationing and offers insufficient choice, and the mosaic of subsystems in the United States, which they consider socially irresponsible because 15 percent of the population younger than 65 years of age has no health insurance. Whether reform measures in France have come from the political left or right, French politicians have defended their health care system as an ideal synthesis of solidarity, liberalism, and pluralism.
(Figure)
Pompidou Hospital, Paris, 2004.
Image: Claude Le Pen.
Beyond a range of tax increases to finance health care, the recent law seeks to implement what the French call la ma?trise médicalisée — a kind of state-led managed care. Like the 1996 reform enacted by then Prime Minister Alain Juppé, it proposes to apply techniques that were designed for managed care organizations in the United States (e.g., computerized medical records, practice guidelines, and incentives to encourage the use of primary care physicians as gatekeepers) to a unitary state system.
The idea of state-led managed care in France has gained momentum over the past decade, but its implementation poses enormous challenges. The idea is compelling for two reasons: it seeks to modernize the health care sector and increase the quality of care, and it promises to control costs by increasing the efficiency of resource allocation within targeted expenditure limits. In these respects, the reform will reinforce the powerful role of the central state, which will oversee vast institutional renovation, apply administrative and information technology to health care, and design incentives and regulations to improve quality. The limitations of state-led managed care, however, are rooted in the centralization of policymaking in France and the successful resistance of the medical profession to all efforts at micromanaging medical practice and second-guessing physicians' authority.2
In contrast to many European nations — such as Britain, the Netherlands, and Germany — France has eschewed two popular ideas in health care reform: consumer choice and price competition among local health insurance funds and selective contracting between these funds and health care providers. The avoidance of these approaches reflects France's commitment to the freedom of beneficiaries to choose among all willing providers, as well as the belief that competition would lead to privatization — an unacceptable departure from the "solidarity" principle, which requires mutual aid and cooperation among the sick and the well, the inactive and the active, and the poor and the wealthy and insists on financing health insurance on the basis of ability to pay, not actuarial risk.
But like the U.S. health care system, the French system is also structured according to principles of liberalism and pluralism, as a market-based economic system with extensive organizational diversity and individual choice. Most physicians in private practice tenaciously support the present arrangements, embracing the principles enshrined in "la médecine libérale": selection of physicians by patients, freedom for physicians to practice wherever they choose, clinical autonomy, doctor–patient confidentiality, and direct payment to physicians by patients who are reimbursed a good share of their expenditures. With limited and experimental exceptions, France does not use primary care physicians as gatekeepers in the way managed-care organizations do in the United States. Although the hospital system is dominated by public hospitals managed by the Ministry of Health and its regional agencies, private practice remains largely unmanaged.3
The NHI system is financed by a mix of mandatory payroll taxes, government general-revenue funds, and a small share of consumer coinsurance. In contrast to Medicare, French NHI coverage increases when a patient's costs increase; there are no deductibles; and pharmaceutical benefits are extensive. Patients with debilitating or chronic illness are exempted from paying coinsurance if they consult physicians who accept NHI reimbursement as payment in full. When patients consult any of the 26.5 percent of physicians who do not do so, a portion of their coinsurance is reimbursed by complementary health insurers, through a system that resembles Medigap coverage for U.S. Medicare beneficiaries. Thus, despite widespread use of coinsurance, patients remain well covered under NHI and enjoy a broad array of choices by European and American standards.
Although French policymakers claim to have a health care system that reconciles solidarity, liberalism, and pluralism, the system has changed decisively. One change is unique to France. The Juppé reform increased fiscal taxes (on income, capital, cigarettes, and alcohol), reducing the share of employer-based payroll-tax financing from 95 percent of total health care expenditures to roughly one half. Since the health system is more heavily dependent on central-government financing, the central state's legitimacy in implementing health care reform has been strengthened. The second change has been driven by the global evolution of medical technology, proliferation of medical specialties, and explosion of medical knowledge — which make most principles of la médecine libérale seem anachronistic and render solo private practice quaint at best.4
There is emerging consensus on some of the conclusions of a recent task force.5 First, the secular growth of health care expenditures will continue. Second, health policy should aim to achieve value for money in the allocation of health care resources and equity in the distribution of services. Third, when expenditures meet these goals, they must be financed collectively. The first and third propositions do not provoke controversy in France. The second proposition, however, forces recognition of two problems that threaten the sustainability of the health care system.
First, it is difficult to control expenditures in a system deeply committed to liberalism and pluralism. Although the French health care system is not expensive compared with that of the United States (see table), France is one of the biggest spenders in Europe. Second, access to care is no longer a sufficient objective, given that the quality of health services is unevenly distributed among both geographic regions and social classes. This problem is exacerbated by patients' freedom of navigation within the system and the increasing consciousness of possibilities offered by state-of-the-art treatments.
Basic Indicators, France and the United States, 2002.
The French health care system has reached a turning point that should interest clinicians and policymakers in the United States, for the current reform represents the French response to a fundamental question: Can the balance among solidarity, liberalism, and pluralism be maintained while health care costs are kept under control and the cherished features of the present system are sustained? The birth of state-led managed care in France has clarified the challenge ahead: Can France adapt the NHI system to the exigencies of technological and economic change without provoking insurmountable opposition from the medical profession? In other words, can the Douste-Blazy reform actually be implemented, or will it provide support for that well-worn aphorism — plus ?a change, plus c'est la même chose?
Source Information
From the Wagner School, New York University, and the World Cities Project, International Longevity Center–USA, New York (V.G.R.); and the University of Paris–Dauphine, Paris (C.L.P.).
References
World Health Report 2000. Health systems: improving performance. (Accessed November 4, 2004 at http://www.who.int/whr/previous/en/.)
De Kervasdoué J. Pour une révolution sans réforme. Paris: Gallimard, 1999.
Rodwin VG. The health care system under French national health insurance: lessons for health reform in the United States. Am J Public Health 2003;93:31-37.
Le Pen C. Les habits neufs d'Hippocrate. Paris: Calmann-Levy, 1999.
Fragonard B. Rapport du haut conseil pour l'avenir de l'assurance maladie. Paris: Ministry of Health, January 2003.(Victor G. Rodwin, Ph.D., )
(Figure)
H?tel Dieu Hospital, Paris, Early 19th Century.
Image: Wellcome Library, London.
French policymakers typically view their NHI system as a realistic compromise between Britain's National Health Service, which they believe requires too much rationing and offers insufficient choice, and the mosaic of subsystems in the United States, which they consider socially irresponsible because 15 percent of the population younger than 65 years of age has no health insurance. Whether reform measures in France have come from the political left or right, French politicians have defended their health care system as an ideal synthesis of solidarity, liberalism, and pluralism.
(Figure)
Pompidou Hospital, Paris, 2004.
Image: Claude Le Pen.
Beyond a range of tax increases to finance health care, the recent law seeks to implement what the French call la ma?trise médicalisée — a kind of state-led managed care. Like the 1996 reform enacted by then Prime Minister Alain Juppé, it proposes to apply techniques that were designed for managed care organizations in the United States (e.g., computerized medical records, practice guidelines, and incentives to encourage the use of primary care physicians as gatekeepers) to a unitary state system.
The idea of state-led managed care in France has gained momentum over the past decade, but its implementation poses enormous challenges. The idea is compelling for two reasons: it seeks to modernize the health care sector and increase the quality of care, and it promises to control costs by increasing the efficiency of resource allocation within targeted expenditure limits. In these respects, the reform will reinforce the powerful role of the central state, which will oversee vast institutional renovation, apply administrative and information technology to health care, and design incentives and regulations to improve quality. The limitations of state-led managed care, however, are rooted in the centralization of policymaking in France and the successful resistance of the medical profession to all efforts at micromanaging medical practice and second-guessing physicians' authority.2
In contrast to many European nations — such as Britain, the Netherlands, and Germany — France has eschewed two popular ideas in health care reform: consumer choice and price competition among local health insurance funds and selective contracting between these funds and health care providers. The avoidance of these approaches reflects France's commitment to the freedom of beneficiaries to choose among all willing providers, as well as the belief that competition would lead to privatization — an unacceptable departure from the "solidarity" principle, which requires mutual aid and cooperation among the sick and the well, the inactive and the active, and the poor and the wealthy and insists on financing health insurance on the basis of ability to pay, not actuarial risk.
But like the U.S. health care system, the French system is also structured according to principles of liberalism and pluralism, as a market-based economic system with extensive organizational diversity and individual choice. Most physicians in private practice tenaciously support the present arrangements, embracing the principles enshrined in "la médecine libérale": selection of physicians by patients, freedom for physicians to practice wherever they choose, clinical autonomy, doctor–patient confidentiality, and direct payment to physicians by patients who are reimbursed a good share of their expenditures. With limited and experimental exceptions, France does not use primary care physicians as gatekeepers in the way managed-care organizations do in the United States. Although the hospital system is dominated by public hospitals managed by the Ministry of Health and its regional agencies, private practice remains largely unmanaged.3
The NHI system is financed by a mix of mandatory payroll taxes, government general-revenue funds, and a small share of consumer coinsurance. In contrast to Medicare, French NHI coverage increases when a patient's costs increase; there are no deductibles; and pharmaceutical benefits are extensive. Patients with debilitating or chronic illness are exempted from paying coinsurance if they consult physicians who accept NHI reimbursement as payment in full. When patients consult any of the 26.5 percent of physicians who do not do so, a portion of their coinsurance is reimbursed by complementary health insurers, through a system that resembles Medigap coverage for U.S. Medicare beneficiaries. Thus, despite widespread use of coinsurance, patients remain well covered under NHI and enjoy a broad array of choices by European and American standards.
Although French policymakers claim to have a health care system that reconciles solidarity, liberalism, and pluralism, the system has changed decisively. One change is unique to France. The Juppé reform increased fiscal taxes (on income, capital, cigarettes, and alcohol), reducing the share of employer-based payroll-tax financing from 95 percent of total health care expenditures to roughly one half. Since the health system is more heavily dependent on central-government financing, the central state's legitimacy in implementing health care reform has been strengthened. The second change has been driven by the global evolution of medical technology, proliferation of medical specialties, and explosion of medical knowledge — which make most principles of la médecine libérale seem anachronistic and render solo private practice quaint at best.4
There is emerging consensus on some of the conclusions of a recent task force.5 First, the secular growth of health care expenditures will continue. Second, health policy should aim to achieve value for money in the allocation of health care resources and equity in the distribution of services. Third, when expenditures meet these goals, they must be financed collectively. The first and third propositions do not provoke controversy in France. The second proposition, however, forces recognition of two problems that threaten the sustainability of the health care system.
First, it is difficult to control expenditures in a system deeply committed to liberalism and pluralism. Although the French health care system is not expensive compared with that of the United States (see table), France is one of the biggest spenders in Europe. Second, access to care is no longer a sufficient objective, given that the quality of health services is unevenly distributed among both geographic regions and social classes. This problem is exacerbated by patients' freedom of navigation within the system and the increasing consciousness of possibilities offered by state-of-the-art treatments.
Basic Indicators, France and the United States, 2002.
The French health care system has reached a turning point that should interest clinicians and policymakers in the United States, for the current reform represents the French response to a fundamental question: Can the balance among solidarity, liberalism, and pluralism be maintained while health care costs are kept under control and the cherished features of the present system are sustained? The birth of state-led managed care in France has clarified the challenge ahead: Can France adapt the NHI system to the exigencies of technological and economic change without provoking insurmountable opposition from the medical profession? In other words, can the Douste-Blazy reform actually be implemented, or will it provide support for that well-worn aphorism — plus ?a change, plus c'est la même chose?
Source Information
From the Wagner School, New York University, and the World Cities Project, International Longevity Center–USA, New York (V.G.R.); and the University of Paris–Dauphine, Paris (C.L.P.).
References
World Health Report 2000. Health systems: improving performance. (Accessed November 4, 2004 at http://www.who.int/whr/previous/en/.)
De Kervasdoué J. Pour une révolution sans réforme. Paris: Gallimard, 1999.
Rodwin VG. The health care system under French national health insurance: lessons for health reform in the United States. Am J Public Health 2003;93:31-37.
Le Pen C. Les habits neufs d'Hippocrate. Paris: Calmann-Levy, 1999.
Fragonard B. Rapport du haut conseil pour l'avenir de l'assurance maladie. Paris: Ministry of Health, January 2003.(Victor G. Rodwin, Ph.D., )