by Isabelle Durand-Zaleski
Equalizing peoples’ conditions produces individualism. “Individualism, at first, only saps the virtues of public life; but in the long run it attacks and destroys all others and is at length absorbed in downright selfishness. Selfishness is a vice as old as the world, which does not belong to one form of society more than to another; individualism is of democratic origin, and it threatens to spread in the same ratio as the equality of condition” (Tocqueville De la démocratique en Amérique, 1835-1840; Chapter II Of individualism in democratic countries).
Reading this passage from Tocqueville may have led French health policy makers of the past decade, regardless of their political inclinations, to implement reforms that contain individualism. This concerns all three stakeholders of the health care system: patients, providers and payers.
The major reform limiting patients’ individualism, for example the ability to control the volume and type of the care they seek, dates back to the 2004 Social Security Reform Act. In order to claim full reimbursement, patients had to agree to a referring physician (akin to a gatekeeper). This was meant to put an end to what was described by a former director of the social health insurance as medical tourism: “three GPs in the morning, four specialists in the afternoon, and evening trading at the hospital”. The supporting evidence for tourism was anecdotal but the symbolic value was huge. In 2012 the Social Health Insurance limited the third party payment mechanism only to patients who accepted generic drugs which resulted in an increase of almost 10% in the use of generics.
All providers were targeted by recent reforms, albeit in different ways. Physicians have so far upheld their ability to choose the location of their practice, but other health professions agreed since 2009 to practice in underserved areas in exchange for higher fees. The physician-owned clinics have been replaced by corporation-owned clinics though closures and mergers. Although recent mergers have been spectacular, the limitations of private clinics’ individual choices were older, with control over their location and activities. The most recent and still hotly debated (the law is not voted as of 30 November 2015) reform is the universal third party payment system for all self-employed general practitioners. This proposed reform allows patients to be treated without paying the fee which will be directly credited to the physician’s account by the Social Health Insurance. Patients will pay only the amount of extra billing (if any). This measure has been opposed by the physicians on two grounds at least. Technically, they fear that the money will not be credited on time or that there will be errors. A broader consequence is that self-employed physicians will become entirely dependent of the SHI for receiving income in a timely manner. They will become in effect employees of the SHI (which previously reimbursed patients) instead of rendering a service to patients.
After patients and providers, the third stakeholder in the field is the payer. While the core health insurance is mandatory with no choice, some degree of choice was permitted for the complementary health insurance. Individuals who were not covered through a company plan could select their plan and decide on the amount of coverage they wanted to pay for. The 2013 law on secure employment mandates all businesses to provide complementary health insurance to employees: the coverage will be provided by a group plan for all employees and not individual contracts. The mutual funds which traditionally provided individual contracts are weakened by the law while provident institutions historically working with corporations are in a stronger position.
The reforms of the past 10 years may not have been intended to crush individualism in order to save the French democracy, but there seems however to be a pattern which is independent of the political inclination of the government. Right wing politics may favour corporations and Left wing politics the State and the SHI, but both concur to limit individual choices for all stakeholders in the system. How does the population react to the reforms? On the whole, when surveys ask about the reforms that are considered least offensive, there is public support for reducing prescriptions of tests and drugs, incentivising generic prescribing and implementing a gatekeeping system, far more than for limiting reimbursement or increasing premiums. The political risk of antagonising physicians has been limited in the past, but no reform of the magnitude of the universal third party payment has been passed. It was listed in the program of the presidential candidate François Hollande and as such is important to uphold.
About the author
Dr Isabelle Durand-Zaleski is Professor of Medicine at the University of Paris XII. She is also a member of the Editorial Board for the Health Economics, Policy and Law journal.
