55

Case study

France

Zeynep Or and Coralie Gandré

Institute for Research and Information in Health Economics

Paris, France

56 Price setting and price regulation in health care

Price setting and price regulation in health care: France

Abstract 57

1 Background on the French health system 58

Health status 58

Healthcarefinancing 58

Healthcareprovisions 59

Regulationandmanagement 59

Macro-levelcostcontainment 59

2 Price setting for ambulatory services 61

Settingfeesforprimarycareand outpatientspecialistservices 61

Regulationofpricesinsector2 64

Aprogressiveshifttowardsvalue-basedpayment 65

Settingfeesformedicalambulatoryprocedures 68

3 Price setting for drugs and medical devices 70

Settingpricesofdrugsandmedicaldevices usedinambulatorysettings 70

Definitionofpricesofpharmaceuticalsand medicaldevicesusedinhospitals 72

4 Price setting for acute hospital care 73

Hospitalcontext 73

Pricesettinginacutecarehospitals:the DRGpaymentmodel 74

DefinitionofGHMtariffs 75

Usingpricestoregulatehospitalactivity 79

Paymentsforacutepsychiatrichospitalcare 79

5 Price setting for rehabilitation and long-term care (LTC) 80

Inpatientrehabilitationservices 80

Long-termresidentialcareforelderly 80

Annex 1Indicatorstakenintoaccountforbundled paymentstophysicians 83

References 84

Contents

57Price setting and price regulation in health care

TheFrenchsystemencouragespluralityinhealthcareprovision,whichreliesonamixofpublicandprivateproviders.Thisplurality,withahighshareofprivateprovidersworkingunderpublicinsuranceregulation,explainspartlytherelativelygoodresultsconcerningwaitingtimesandpatientsatisfaction.However,thehighdegreeofautonomyandchoicebothforprovidersandpatientstogetherwithprimarilyfee-for-servicepaymentsforhealthcareprovidersrequirescarefulregulationofpricesandofthehealthcaremarkettocontainhealthexpendituresandtotackleissuesofcarecoordination,accessandefficiency.

Thelevelofremunerationofhealthprofessionalsispartlytheresultofthepowerrelationsbetweenthestakeholders.Inasystemwheremosthealthprofessionalsarepaidonafee-for-servicebasisandwherethesocialhealthinsurancefundsactasasinglepayer,theFrenchexperienceshowsthatpriceregulationatthecentrallevelcombinedwithmacro-levelexpenditurecontrolsisinstrumentalforsteeringhealthcareproviders.Francehasputinplacesuccessfullyseveralmechanismsforcontrollingthefeesforproviders,services,medications,etc.atthenationallevel.Theregulationofpricesformajorhealthservicesandmedicationsreducesfinancialburdenofcareforpatientsandallowsimprovedaccessforthewholepopulation.Privateproviderscontractedwithpublicpayersunderregulatedfeescontributetoeasingthepressureonpublicresourcesandsatisfyingtheincreasingdemand.However,theFrenchexperiencealsoshowsthatconcentratingonlyonproviderfees,withoutquestioningthequalityorappropriatenessofservices,isnotenoughforcostcontainmentinthelongerterm.Underfee-for-service,andactivity-basedpaymentinhospitals,providerstendtocompensatefor(potential)lostrevenuesbyincreasingthevolumeandintensityoftheirservices.

Therefore,increasingly,theattentionisturnedonalternativemodesofpaymentwithdevelopmentofvalue-basedcontractsandbundlepaymentstoincentivizequalityofcarebothintheambulatoryandhospitalsector.Inthehospitalsector,thereisalsoagrowingtendencytousepricesforencouragingtreatments,whichareconsideredas“betterpractice”ordiscouraging“lowvaluecare”ratherthanpayingforanyvolumeofactivity.

Abstract

58 Price setting and price regulation in health care

1 Background on the French health system

Health status

Franceisahigh-incomecountrywithrelativelygoodhealthoutcomes.Comparedwithotherindustrializedcountries,Francerankshighintermsoflifeexpectancybothatbirthandatadvancedage.Inparticular,olderpersonsremaininbetterhealthwithoneofthehighestlifeexpectanciesattheageof65overamongOECDcountries(24yearsforwomenand19yearsformen)(OECD,2018a;2018b).Cancersurvivalrates,whichareoftenusedasamoredirectindicatoroftheperformanceofthehealthcaresystem,arealsohighcomparedwithmostotherEuropeancountries(Eurocare,2014).Atthesametime,Francesuffersfromahighrateofprematuremaledeathsfromaccidentsandunhealthyhabits(smokingandalcoholism),andsocialandgeographicinequalitiesinhealthremainsubstantial(LangandUlrich,2017).

Health care financing

Healthcareisfinancedviaasocialinsurancesystemwherethecoverageiseffectivelyuniversal.Health-relatedcostsarecoveredbyamixtureofcompulsorysocialhealthinsurance(SHI)andprivatecomplementaryhealthinsurance(CHI)schemes.Thebenefitpackageiscomprehensive,uniform,andofoverallgoodquality.Inaddition,Francehasoneofthelowestlevelsofout-of-pocketpaymentsamongOECDcountries(OECD,2017).

EnrollmentinSHIdependsontheemploymentstatusandisautomaticforworkers(coveringtheirspousesanddependentchildren).Consumerscannotchoosetheirschemeorinsurerandcannotoptout.Since2000,thereisastatefundedscheme,UniversalMedicalCoverage,forvery-lowincomegroups(Couverture Maladie Universelle,CMU).TherearenocompetinghealthinsurancemarketsforthecorehealthcoverageinFrance.Thereishoweveraverycompetitiveprivatecomplementaryinsurancemarketwithabout95%ofthepopulationowningprivateCHI.Thisisduetothefactthatpatientsneedtopaypartofthecostforalmostallservices,includingdoctorconsultations,hospitalcareandprescriptions.CHIismostlyusedtocovertheshareofcostlefttopatientsforservicesincludedinthepublicbenefitbasket.

FundingoftheSHIcomesmainlyfromincome-basedcontributionsofemployersandemployees,andincreasinglybytaxesonabroaderrangeofincomewithadditionalrevenuesfromearmarkedtaxesontobacco,alcohol,pharmaceuticalcompanies,etc.

59Price setting and price regulation in health care

Health care provisions

Healthcareprovisionsrelyheavilyonprivateproviders.Ambulatorycareismainlyprovidedbyself-employedprivatehealthprofessionalsincludingphysicians(generalpractitioners[GPs]andspecialists),nurses,dentistsandmedicalauxiliaries,workingintheirownsolopracticeorinhealth/medicalcentresandhospitaloutpatientdepartments.Morethanhalfofallsurgeriesandonefourthofobstetriccareareprovidedbyprivate-for-profithospitalsthatarecontractedwithandpaidbytheSHIfund.

Historically,healthcareisorganizedaroundfourprinciplesdelineatedbylaw:confidentialityofmedicalinformation;freedomofpracticeforphysicians;patient’sfreechoiceofprovider;andoffice-basedfee-for-service(FFS)practiceintheambulatorysector.Doctorsarefreetochoosewhereandhowtheypractice.Patientshavefreeaccesstoanyphysicianoranyfacilitywithnolimitonthefrequencyofvisits.Thereisverylittlecontrolofaccesstohospitalandspecialistcare.Whilesomeoftheseprincipleshavebeenchallengedwithrecentreforms,thereisstillahighdegreeofindependenceandchoicebothforprovidersandpatients.

Regulation and management

Theregulationandmanagementofthehealthcaresystemismainlydividedbetweenthestate(parliamentandgovernmentwithseveralministries)andthestatutoryhealthinsurancefunds.Thestate/governmentsetsoutsector-levelexpendituretargets,determinesthelevelsofhealthcareprovisionandtraining,regulatescarequality,anddefinespriorityareasfornationalprograms.Ontheotherhand,thestatutoryhealthinsurancefundsplaythemainroleindefiningthebenefitbaskets;regulatingthepricesofprocedures,drugs,anddevices,whichwillbereimbursedtopatients;anddefiningthelevelsofcopayment.Statutoryhealthinsuranceoverseessettingtariffsforhealthprofessionalsinprivatepracticeviacollectivenegotiationswithprofessionals’unions.

Macro-level cost containment

HealthisthesecondlargestareaofpublicspendinginFrance.Healthcareandothersocialsecuritydeficitshavebeenapersistentproblemoverthecourseofthe2000s.Thespecificationofanoverallexpendituretargetforhealthcare,knownastheNationalObjectiveforHealthInsuranceSpending(Objectif National de Dépenses d’Assurance Maladie,ONDAM),hasbeenakeyaspectoftheFrenchstrategytocontrolhealthspending.Thisinvolvessettinganaprioriglobalbudgetforhealtheachyear.Traditionally,theFrenchgovernmenthasnotplayedaproactiveroleincontrollingoverallhealthcarespending,withindependentlyoperatedcompulsoryinsurancefundsresponsibleformanagingtheirownspending.ONDAMmarkedasignificantbreakfromthistraditionandrepresentsthereassertionofthegovernment’scontrolofhealthcarespending(Barroyetal.,2014).

60 Price setting and price regulation in health care

ONDAMisspecifiedinmonetarytermsasthetotalamountofhealthspendingfortheforthcomingcalendaryearandgivesallstakeholdersapreciseobjectiveintermsofspending.ThemonetaryONDAMtargetisusedtosignalthepercentageofhealthspendinggrowththatthegovernmentiswillingtoacceptinanygivenyear.ONDAM’soveralltargetissplitintothreesubtargetsforthemainhealthserviceproviders:ambulatorycare,hospitals,andmedico-socialfacilities.Thebudgetsforhospitalandmedico-socialfacilitiesarefurtherdividedintotwoenvelopes,oneforpublicandprivatenon-profithospitalsandoneforprivatefor-profitones.

Initiallysetasobjectives,ONDAMtargetsbecamebindingovertimewithadedicatedcommitteefollowingtheevolutionofhealthexpenditurestowardmoreresponsibilityandpowersforthehealthinsurancefundscontaincosts.Despitetheinitialuncertaintyofitsinfluence,thebudgetaryprocessesusheredinbyONDAMappeartoachievebettercontainmentofhealthexpendituresaswellasbetterworkingrelationsbetweenstakeholders.Thegrowthrateofhealthexpenditureshasbeendecreasingforadecade,andONDAMtargetshavebeensuccessfullymetsince2010(Figure1).

Figure 1 Evolution of health expenditure growth against ONDAM targets

2004

2005

2006

2007

2008

2009

6

5

4

3

2

1

0125 135 145 155 165 175 185 195

2011

2010

2012

2013

2014

20152016

2017 2018

%

Source:CCSS,2018.Note:Theabscissashowsexpenditureinbillionsofeuroandtheordinateshowsgrowthrate.Thesizeofeachbubblerepresentstheextentofthedeficit(inlightblue)orsurplus(indarkblue)withrespecttotheONDAMtargetvotedintheparliament.In2018,totalexpenditureofhealthinsurancefundswas€195.2billion,representingaconstantgrowthrateof2.3%,whichisslightlyunderthesettarget.Incomparison,theONDAMtargetwas4%in2004,whiletheactualgrowthrateobservedwas4.9%.

61Price setting and price regulation in health care

2 Price setting for ambulatory services

HealthprofessionalsworkingintheambulatorysectorandthoseworkinginprivatehospitalscontractwiththehealthinsurancefundandarepaidonaFFSbasis.Thepricesoftheservices(consultationsandprocedures)providedbytheseprofessionalsaresetatthenationallevelbytheSHIfund.

Setting fees for primary care and outpatient specialist services

PrimarycareandoutpatientspecialistservicesaremostlyfundedonanegotiatedFFSbasis.However,recentinitiativesfromtheSHIfundhavetweakedthefundingbyintroducingapay-for-performance(P4P)schemethatiscompletedbystructuralbundledpayments.Thefeesaresetthroughformalnegotiationsbetweentheunionofstatutoryhealthinsurancefunds(UNCAM),thegovernment,theunionofcomplementaryhealthinsuranceschemes(UNOCAM)andunionsofhealthprofessionals,whichledtoanationalcollectiveagreement(convention nationale),acontractthataimstoregulatetheexpenditureandactivityoftheambulatorysector.Thesenegotiationshavebeennationalsincethe1970sandleadtouniformfeescorrespondingtoofficialtariffsforreimbursementbySHI(Régereau,2005).UNCAMfirstprovidesaproposalwhichtakesintoaccountfinancialconstraintssetbythesub-targetofONDAMfortheambulatorysector.Theproposalsetstheprinciplesandmodalitiesforrespectingtheexpendituretarget(notably,modificationoftariffsorfeesforservices)aswellasarangeofmeasuresforincentivizingbettermedicalpracticetoachievetheprioritiessetbytheSHIfund(suchasbettergeographicalandfinancialaccesstocare,improvingcarecoordination,healthpreventionandpromotionandqualityofcare)(Union nationale des caisses d’assurance maladieetal.,2016).

TheUNCAMproposalisdiscussedwithdifferentproviderunions.Medicalprofessionals’unionsexertconsiderablepowerthroughlobbyingintheparliament.TheMinistryofHealththereforeplaysasignificantroleinthenegotiations,whichcanbecomplicatedbetweenUNCAMandunionsofphysicians,inparticular.Unionsobtainingmorethan30%ofthevotesfromtheirprofessionalgroupscansigntheagreementontheirown,whilethoseobtainingbetween10%and30%ofthevotesneedtosigntheagreementtogetherwiththeotherunions.Agreementsforeachprofessionalgroupcoveraperiodoffiveyears.Atthesametime,regularamendmentsoccur(atleastannuallyfordoctors)toadjustforchangesdemandedbytheSocialSecurityFinanceAct,whichsetstheONDAMexpendituretargetsanddefinesnewprovisionsandmeasurestoreachthetargetseachyear.

62 Price setting and price regulation in health care

Traditionallythefeeshavebeenincreasedregularly,mainlybytakingintoaccountinflationanddependonthebargainingpoweroftheprofessionalunions(Figure2).In2011,theSHIfundhadintroducedaP4Pscheme(seebelow)andfrozethepricesuntil2016.However,inthenationalagreementofAugust2016(justbeforethepresidentialelections),physiciansobtainedasignificantincreaseintariffs(from€23to€25foraregularGPconsultationandfrom€28to€30foraregularconsultationwithmostspecialists).Thisagreementintroducedhigherfeesforconsultationswithcomplexpatients(atariffreaching€50)andverycomplexpatients(withatariffof€60)(CNAM,2018c).Theseconsultationsarededicatedtopatientswithmultiple,complexandunstableconditions,andtospecificserviceswithstrongpublichealthstakes(suchasscreeningandprevention).ThevisitsthatcanbenefitfromthesenewtariffsaredefinedbytheSHIfundinthenationalagreement.Complexconsultationsinclude,forexample,visitsforcontraceptionandpreventionofsexually-transmitteddiseasesforteenagers,whileverycomplexvisitsinclude,forinstance,initialvisitstoorganizetreatmentsforseverechronicconditions,suchascancerandneurodegenerativedisorders(Union nationale des caisses d’assurance maladieetal.,2016).Since2016,theSHIfundhasalsoofferedalump-sumpayment(of€50000)forphysicianssettinguptheirpracticeinamedicallyunderservedregionwithacomplementarypaymentofupto€5000peryeartocompensatelowrevenuesinlesspopulatedareas.

Allmedicalprofessionalsaresubjecttothetermsofthenationalagreement,exceptiftheyexplicitlychoosetooptout(lessthan1%ofallphysicians),inwhichcasetheirconsultationfeesarenotreimbursedatall.TheSHIfundpaysthesocialcontributions,includingthepension,ofphysicianswhoagreetochargepatientsonthebasisofthenationallynegotiatedfees(calledsector1contractors).About75%ofprivatephysiciansaresector1contractorsandaregenerallynotallowedtochargehigherfeeswithveryfewexceptions1 (FranceAssosSanté,2017).

SomephysiciansanddentistsareallowedbySHItochargepriceshigherthantheregulatedfees(sector2contractors)basedontheirlevelandexperience.Doctorsworkingassector2contractorsarefreetochargehigherfees,butmustpurchasetheirownpensionandinsurancecoverage.Thecreationofsector2contractorsin1980aimedtoreducethecostofsocialcontributionsfortheSHIfund,butdidnothavetheexpectedimpact,andthedemandforthesectorwasmuchhigherthanpredicted.Consequently,accesstosector2hasbeenlimitedsince1990;eachyear,only1000newdoctorsareallowedtoworkinsector2.2

1 When patients do not respect the gate-keeping system (médecin traitant) developed under the 2004 Social Security Finance Act to support coordinated care pathways, the physician is allowed to charge a supplemental fee (maximum 17.5% of the nationally negotiated fees) that complementary insurances are not allowed to cover.

2 The attributes of doctors allowed to work in sector 2 are listed in the national agreement and include doctors with previous public hospitals positions (former medical chief resident, former hospital assistant, hospital practitioner appointed permanently, and part-time practitioner with at least five years of experience) and physicians or surgeons in the army.

63Price setting and price regulation in health care

Theamountexceedingtheregulatedprice(balancebilling)isnotcoveredbySHIbutcanbecoveredbyprivateCHI.Nevertheless,thegenerosityofCHIcontractsvarieslargelywithdifferentpricelimitsonextrabilling.Aroundonequarterofphysiciansaresector2contractors,butthisproportionshowsstrongvariationacrossregionsandmedicalspecialtiesandishigherforspecialists(43%)thanforGPs(10%)(FranceAssosSanté,2017).

Figure 2 Evolution of ambulatory care spending

Type of spending 2016 2017 Percentage change (2016-17)

Contribution to growth (%)

Share of spending (%)

Mean annual growth between 2006 and 2016 (%)

(in million €) (in million €)

Medical fees

Generalpractitioners 5889 6054 2.8 8.1 8.4 2.6

Specialists 9677 10008 3.4 16.3 13.9 2.9

Midwives 228 248 8.6 1 0.3 10.4

Dentists 2762 2807 1.6 2.2 3.9 1.4

Allied health professionals’ fees

Nurses 5384 5631 4.6 12.2 7.8 8.1

Physiotherapists 3233 3325 2.8 4.5 4.6 4.6

Speechtherapists 605 628 3.8 1.1 0.9 5.8

Orthoptists 67 70 4.1 0.1 0.1 6.2

Medical laboratories

Total 2899 2935 1.2 1.8 4.1 1

Health products

Drugs 19361 19595 1.2 11.5 27.2 1.4

Medicaldevices 5395 5614 4.1 10.8 7.8 6.9

Source:CCSS,2018.BasedondatafromSHI(Caisse nationale de l’Assurance Maladie, Régime général).

64 Price setting and price regulation in health care

Regulation of prices in sector 2

Pricessetbysector2physiciansabovetheregulatedtariffmayormaynotbecoveredbyCHIdependingonthecontract.Thismeansthatforsomepatients,out-of-pocketpaymentstoseeaphysicianmaybetoohigh,whichraisesconcernsbothonequityofaccesstocareandhealthcareexpendituregrowth,sinceunregulatedpricescouldbehighlyinflationary.Therefore,theSHIfundhasintroducedseveralregulatorymechanismsandtoolstocontrolthepricesinsector2.

First,foremergencycareandwhenpatientsarecoveredunderlow-incomeschemes(couverture maladie universelle complémentaire,CMU-C,oraide au paiement d’une complémentaire santé,ACS),balancebillingisnotallowed.Theseschemesarepartlyfundedbythestatewiththeobjectiveofreducingtheburdenofcost-sharingforthesepopulations.Sector2doctorshavetochargenational/negotiatedtariffstopatientswithCMU-CandACS.

Second,thesocialsecuritycode(SectionL162-1-14-1)aswellasthemedicalcodeofethicsimposethatbalancebillingshavetobeareasonableamount(tact et mesure).Untilrecently,therewasnoregulatoryorlegislativedefinitionoftheterm“tact et mesure”orwhatisconsideredtobeareasonableamount.In2012,underpressurefromtheSHIfund,theFrenchnationalmedicalcouncil(Conseil national de l’ordre des médecins,CNOM)recognizeditasafeeexceedingthreeorfourtimestheregulatedprices.

Morerecently,SHIintroducedanewcontractinordertoregulatepriceschargedbysector2physicians:“controlledtariffoption”(option de pratique tarifaire maîtrisée,OPTAM),whichisayearlyandoptionalcontract.Physicianswhochoosethiscontractcommittofreezetheirfees(attheaverageofthethreepreviousyears)andnottochargemorethandouble(100%)theregulatedtariff.Theyarealsoaskedtoperformashareoftheirservicesatregulatedtarifflevels.Inreturn,theyreceiveabonusproportionaltotheshareoftheiractivityrespectingtherules.Thereisalsoanoptionwithsimilarmodalitiesforspecialistswhoperformedatleast50surgicalorobstetricalprocedures/yearinprivatepracticeorinhospitals(option de pratique tarifaire maîtrisée chirurgie et obstétrique,OPTAM-CO).In2017,morethan12,000doctors,representingcloseto40%ofsector2contractors,havesignedthiscontract(Foult,2017).

Penaltiesexistforphysicianswhodonotcomplywiththerequirementsoftheirsector.TheyincludeanadjournmentofthepaymentofsocialcontributionsbySHIforphysiciansinsector1ortheadjournmentoftherighttoextrabillforphysiciansinsector2.

65Price setting and price regulation in health care

A progressive shift towards value-based payment

Whiletheexistingsystem,basedoncollectivenegotiations,canbeconsideredaseffectiveforcontrollingpricesofservices,itisnotentirelyeffectiveforassuringcostcontainmentintheambulatorysector.Overall,between2006and2016,physicianrevenueshaveincreasedonaverage2.8%annually,whichislargelyaboveinflationbasedontheconsumptionprices/index(Figure2).Physiciansappeartoincreasethevolumeoftheirservicesforachievingatargetincome.Increasingly,theSHIfundquestionsthevalueorqualityofservicesprovidedwithaprogressivedevelopmentofvalue-basedpaymentsinprimarycare.Giventhehighleveloffreedomofchoiceforpatients,supportingGPsasgatekeepersinthesystemtoimproveboththequalityandtheefficiencyofthecareprovisionhasbeenanimportantpillarofreformsinthepastdecade.

Sincethe2005nationalagreement,GPshavecommittedtoimprovethecarecoordinationoftheirpatients,promotepreventionandimprovetheirpatients’prescriptionhabitsbyrespectingguidelines,reducingtheoverallvolumeofprescriptionsandincreasinggenericprescriptions(whichisverylowinFrance–seeFigure3).Inreturn,theyhavebenefitedfromanincreaseintheirconsultationfees.However,theseobjectiveswerenon-bindingforindividualphysiciansandhavethereforehadlimitedimpactonGPs’practice.Therefore,in2009,SHIintroducedP4Pcontractsforimprovedindividualpractice(contrats d’amélioration des pratiques individuelles,CAPI)forGPsinanattempttoenhanceandsupportthequalityofprimarycareandmoreefficientprescribing.Thedevelopmentofthesecontractswasfacilitatedbythe2004reformintroducingthepreferreddoctorscheme,whichenabledtheidentificationofapatientlistperphysician.Thecontracts,initiallyproposedtoprimarycarephysiciansandsignedonavoluntarybasisbyindividualGPs,hadthesameobjectivesintermsofimprovingclinicalqualityofcareandencouragingpreventionandgenericprescription,butdidnotaltertheexistingFFSscheme.ParticipatingphysiciansreceivedadditionalremunerationsontopoftheirnormalFFSincomeiftheymetthetargetsset:upto€7000annuallyifalltargetswereachievedorproportionallytotheirprogressifobjectiveswerenotfullyachieved(Bousquet,BisiauxandLingChi,2014).Despitealackofevaluationoftheimpactonoutcomesandcosts,SHIdecidedtoextendthescheme.ItwasgeneralizedtoallGPsinthe2011nationalagreement,whichstipulatedthatthepaymentofprimarycareproviderscouldberelatedtotheirperformance.TheP4Pschemewasrenamed“thepaymentforpublichealthobjectivesscheme”(“rémunération sur objectifs de santé publique”,ROSP)andextendedtootherphysicians.

66 Price setting and price regulation in health care

Figure 3 Market share of generic drugs in selected countries

0 10 20 30 40 50 60 70

France

Norway

Italy

Spain

Finland

UK

Germany

Netherlands

2011

2015

Generics as a percent of market share

ThisP4Pschemerepresentsasignificantchangeinparadigm,asthisnewP4PschemehasofficiallyreplacedthetraditionalincreaseintheFFStariffs,whichwereregularlyobtainedbyphysicianswithoutbeingaccountableindividuallyfortheirresults.Thisnewschemehasbeenprogressivelyextendedtospecialists,startingwithcardiologists,gastroenterologistsandendocrinologists,andnowcoversallphysicianswhosignedthenationalcollectiveagreementof2016.However,physiciansareallowedtooptoutbywritingtotheirlocalhealthinsurancefundinthethreemonthsfollowingthenationalcollectiveagreement(Union nationale des caisses d’assurance maladie et al.,2016).Thereare29indicatorsinthelatestversionoftheROSPscheme(25arecalculatedfromtheclaimsdataandfourrelyonphysicians’ownstatements).Initiallythelistincludedstructuralindicators(mostlyrelatedtoorganizationoftheofficepractice),buttheynowonlyfocusonmedicalpracticeinthreeareas:prevention(forinstancecounselingforsmokingcessationorvaccination)andscreening(inparticularforcancer);follow-upofchronicdisorders(suchasthefollow-upofcardiovascularrisk);andefficiencyofdrugprescriptions(withtheobjectiveofreducinginadequateprescribingandincreasinggenericprescriptions)(CNAM,2018c).Indicatorscanvaryaccordingtothetypeofdoctorinvolved(GPforadultsorchildren,cardiologist,gastroenterologistorendocrinologist).Targetsarefixedduringthenationalcollectivenegotiationsbetweenthestakeholdersbasedonnationalgoodpractice

67Price setting and price regulation in health care

guidelinesortakingtheaveragepracticeasbaselineifthereisnosuchguideline.Thereisnopenaltyforphysicianswhodonotreachthetargets.

ItisdifficulttomakeaconclusiononthecostefficiencyoftheP4PschemeinFrancesincethereisnoproperevaluationofthereform.Thenationalhealthinsurancefundreportssomeimprovements,inparticular,concerningcolorectalcancerscreeningandantibioticsprescription.However,itisdifficulttodisentangletheeffectoftheschemefromotherprogramsintroducedrecentlytoimprovethequalityofcaresuchasnationalawarenesscampaignsforcancerscreening.ThetotalannualcostoftheROSPschemereached€250millionin2017,withtheaverageannualsumearnedthroughthatschemereaching€4522forGPs,€1726forcardiologistsand€1436forgastroenterologists(CNAM,2018c).WhiletheintroductionofROSPappearedtobecost-neutralinitially,withslowerincreasesinpricesandvolumes,itisnotclearyetwhatwillbetheimpactofthelatestincreasesintariffsonoverallexpenditure.Therefore,whiletherehasbeenaprogressiveshifttowardsmorevalue-basedpaymentwithanannualgrowthrateof9.1%inSHIspendingdedicatedtoP4Pbetween2012and2016andanincreasednumberofphysicianscoveredbyP4Pschemes,thisstillrepresentsasmallpartofphysicianincome(Figure4).

Inthe2016nationalcollectiveagreementwithphysicians,structuralindicatorspreviouslyincludingtheROSPschemebecamepartofaspecificbundledpaymentforallphysicianswhatevertheirmedicalspecialty.Thebundleisdividedintwoparts:oneforimprovingtheorganizationofofficepractice(inparticularthedevelopmentofelectronicrecords),andtheotherforprovidingbetterservicestopatients(suchasparticipationintraining,patienteducation,etc.;seeAnnexforthelistofindicatorsused).Physiciansearnabundledpayment,whichcanreachupto€1750yearly,iftheymeetalltheindicators.Thetotalbundleisexpectedtoincreaseto€4620over2019-2020(CNAM,2018b).

68 Price setting and price regulation in health care

Figure 4 Share of P4P in GP revenues: evolution between 2008 and 2017

Mill

ions

of

EURO

s

P4P

Capitation

Medical procedures

Over-billing for consultation and visits

Consultations and visits

0

1000

2000

3000

4000

5000

6000

7000

8000

2017201620152014201320122011201020092008

Source:DREES,2018.

Setting fees for medical ambulatory procedures

MedicalambulatoryproceduresarefundedonaFFSbasissimilarlytoconsultationsandarealsosubjectedtothesameregulationsofover-billing.Theyaccountonaverageforabout50%ofthefees(revenues)receivedbyprivateproviders(CNAM,2018a).However,since2005,thepricesofambulatoryprocedureshavebeenvaluedseparatelyfromconsultations.ThefirststepwasthecreationofaFrenchclassificationofmedicalprocedures(classification commune des actes médicaux,CCAM)definingtheestimatedtimeandcostsofperformingeachprocedureinordertoassignatariff.Thisclassificationhasbeendevelopedduringnearlyadecade.Theobjectivewastopromoteequitablefeesformedicalproceduresforalldoctorsandbetweendifferentspecialtiesinordertoavoidtheselectionofproceduresbasedontheirprofitability(Bras,VieilleribiereandLesteven,2012).

69Price setting and price regulation in health care

CCAMcurrentlycoversmorethan8000medicalproceduresandincludesimagingprocedures,technicalmedicalprocedures(suchasdiagnosticprocedures),surgical,obstetricalanddentalproceduresaswellasproceduresofanatomo-cytopathology.EachactishierarchizedaccordingtoamethodologypartlybasedontheResource-BasedRelativeValueScale(RBVRS)developedintheUSforphysicianservices(Hsiaoetal.,1988).ThetariffofeachmedicalactinCCAMiscalculatedbyaddinganestimatedcostrelatedtomedicalwork(coût du travail medical)toanestimatedcostrelatedtoofficepractice(coût de la pratique).Thecostrelatedtomedicalworkisexpressedasaglobalscore(score travail)andtakesintoaccounttheefforttoperformtheprocedure(time,stress,mentaleffortandtechnicalskills)foraregularpatient.Thisscoreisconvertedintoamonetaryvalueineurosbysettingaconversionfactor.ItsvalueissetinthenationalcollectiveagreementbetweenUNCAMandhealthprofessionals,similarlytoconsultationtariffs.Thecostsrelatedtomedicalpracticecoverstructuralcostssupportedbyhealthprofessionals(staff,rent,socialcontributions,etc.)ineachmedicalspecialty(Bras,VieilleribiereandLesteven,2012).

Thiscomplexsystemforfixingthepricesofmedicalprocedureshasfacedseveraldifficulties.First,strongpressurefromtheunionsofhealthprofessionalsresultedinasituationwheretariffssetfornewproceduresviathisclassificationwereneverlowerthanthepreviousonesevenwhenthecostscalefromtheclassificationsuggestedlowertariffs.Second,therehasbeennoregularupdateoftheestimatedcoststotakeintoaccountevolutionsinmedicalpracticeandtechnologyovertime,exceptforimagingprocedures.Third,thenumberofmedicalproceduresconsideredinFranceappearsimportantincomparisontoothercountries(forinstancemorethan8000vs.5200inthecurrentrevisionoftheAustralianclassificationofmedicalprocedures)(TaskForce“Réforme du financement du système de santé”,2019).In2016,thenationalcollectiveagreementdecidedthatCCAMshouldberevised.AnewcommissionisnowinchargeofgradingmedicalprocedureswithinCCAMandreducingthedelaysinregistrationofnewprocedures(Union nationale des caisses d’assurance maladie,2016).

70 Price setting and price regulation in health care

3 Price setting for drugs and medical devices

Setting prices of drugs and medical devices used in ambulatory settings

Thepricesofdrugsandmedicaldevicesareregulatedthroughmultiannualframeworkagreementsbetweenthestate,whichisrepresentedbytheEconomicCommitteeforHealthcareproducts(Comité économique des produits de santé,CEPS),andthepharmaceuticalindustrysince1994(Grandfils,2008).Theagreementdefinescommonobjectivesformarkettrends(intermsofexpenditure)aswellaspricesettingmechanisms.Thelatestagreementwassignedin2016forthreeyears.Intheframeofthisagreement,pricesofdrugsarenegotiatedbetweeneachpharmaceuticalcompanyandCEPS.Pricesarere-evaluatedeveryfiveyearsaccordingtosimilarmodalities.Themainelementsthataretakenintoaccountinthenegotiationsincludetheaddedtherapeuticvalueofthedrug(amélioration du service médical rendu,ASMR),whichismeasuredincomparisontotheclinicalbenefitsofexistingdrugsortherapiesinthemarketandvariesfrom1(thehighestaddedtherapeuticvalue)to5(thelowesttherapeuticvalue),aswellasitscost-effectiveness(since2012),asassessedbytheNationalHealthAuthority(Haute autorité de santé,HAS).Inpricenegotiations,thepricesofotherdrugswiththesametherapeuticobjectiveandtheexpectedorobservedvolumesofsalesarealsotakenintoaccount.Ifthereisnoagreementbetweenthetwoparties,CEPSsetsunilaterallythepriceofdrugs,butpharmaceuticalcompaniesbenefitfromsomeguaranteesfordrugswithasignificantclinicaladdedvalue.Fordrugswithanaddedvalueof1,2,3orinspecificcases4,thepricesetcannotbelowerthanthepriceinfourreferenceEuropeanmarkets(Germany,Spain,ItalyandtheUK).ThisguaranteeistomakeFranceanattractivelocationfortheearlymarketingofinnovativedrugs(Courdescomptes,2017).

Thepriceofadrugissetbeforethedecisiontoincludeit(ornot)inthepublicbenefitpackage.TobereimbursedbytheSHIfund,drugshavetobeevaluatedandregisteredinapositivelist(liste des spécialités pharmaceutiques remboursables).ThepricesaredefinedbytheMinistryofHealthbasedontheadvicefromHASandCEPS,whilethereimbursementrate(65%,30%,15%or0%)isdefinedbytheSHIfundbasedonthetherapeuticvalueofthedrug(service médical rendu,SMR).SMRisassessedbyHASandtakesintoaccounttheseverityoftheillnesstargetedbythedrug,itseffectiveness,itsimpactonpublichealthanditssideeffectswithregardstoallotherdrugsortreatmentstargetingthesamehealthcondition.Traditionally,complementaryinsurancefundscoveredtheremainingcostsforpatientsofanyreimburseddrug.Since2012,theSHIfundencourages(withtaxreturnsforresponsiblecontracts)theCHIfundstoreimburseonlythecostofdrugswithamajorandimportantSMR,butthecoverageofcostsbyCHIvaries

71Price setting and price regulation in health care

significantlydependingonthetypeofcontractchosenbythebeneficiary.FordrugsreimbursedbySHI,thepricesetbyCEPSservesasabasisforreimbursement,whilethepricesofdrugsthatarenotincludedinthebenefitpackagearenotregulated.Between2008and2017,thepricesofdrugsnotreimbursedincreasedbyabout20%,whilethepricesofdrugsonthepositivelist(reimbursed)droppedbyabout30%(Figure5).

Figure 5 Trends in drug prices over time (Price in 2008=100 as reference)

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

130

120

110

100

90

80

70

60

Non-reimbursed drugs

All drugs

Reimbursed drugs

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8=10

0

Source:DREES,2018.

Therefore,thispricesettingmechanisminFranceappearstobesuccessful,sincedrugpricesinFrancearerelativelylowincomparisonwithotherOECDcountries(Figure6).

72 Price setting and price regulation in health care

Figure 6 Drug prices for the 30 most commonly prescribed drugs, 2006–2007

0.0

0.2

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New ZealandFranceNetherlandsAustraliaUKSwitzerlandGermanyCanadaUSA

Dru

g pr

ices

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e pr

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Source:CommonwealthFund,2019.Note:USApricesaresetasreferenceat1.0

Definition of prices of pharmaceuticals and medical devices used in hospitals

Thepricesofhospitaldrugsweresetfreelyvianegotiationsbetweenpharmaceuticalcompaniesandindividualhospitalswithoutanyregulationuntil2004.Therefore,thesamedrugcouldhavedifferentpricesindifferenthospitalsdependingonthehospital’snegotiatingpower.Withtheintroductionofactivity-basedpayment(ABP),mostdrugsarenowincludedinthetariffsofthediagnosis-relatedgroups(DRG).Whiletheirpriceisnotdirectlyregulatedandisstillnegotiatedbetweenthepharmaceuticalindustryandhospitals,drugsarereimbursedtohospitalsbythehealthinsurancefundinthelimitofamaximumfixedtariff(tarif de responsabilité),whichbecomesinpracticetheregulatedprice.Thistariffissetaccordingtomodalitiessimilartothoseusedtosetthepricesofdrugsintheambulatorysector(throughtheinvolvementofCEPS).

Furthermore,therearesomespecificmeasuresforregulatingthecostsofveryexpensiveandinnovativedrugs.TheirsignificantcostrelativetoDRGtariffsaswellastheneedforassuringquickaccesstoinnovationjustifiedthedevelopmentofalistofdrugsforwhichpaymentsaremadeontopofDRGtariffs.Thesedrugs(mostlyforcancer)areincludedonaspecificlist(liste des médicaments facturables en sus des prestations d’hospitalisation)basedonstrictcriteria(astrong

73Price setting and price regulation in health care

addedtherapeuticvalueofthedrug,acostsuperiorto30%oftheDRGtariff,andanindicationforlessthan80%ofthepatientsincludedintheDRG).AspecifictargetedbudgetforthislistofdrugsissetinONDAM,andthepricesofthesedrugsareregulatedvianegotiationsbetweeneachpharmaceuticalcompanyandCEPSmainlyusingEuropeanprices(inGermany,Italy,SpainandtheUK)asareference.Whilethisprocedurehasbeencreatedasatemporaryoptionforfundinginnovation(onceadrugispartofregulartreatment,itshouldbeincludedintheDRGtariff),inpracticethenumberofexclusionsfromthelistovertimeislow(Gandré,2011).

Expenditureforthesedrugsanddeviceshasincreasedbyalmost20%between2011and2015(18.5%fordrugsand23%formedicaldevices)toreach€4.8billion(5.3%oftotalhospitalcarespending).Risingspendingismostlydrivenbythepublicsectorandbydrugsforthetreatmentofcancerandautoimmunediseases.Whiletherewere150drugsonthelistin2015,10drugsaccountedfortwothirdsofthetotalexpenditureassociatedtothelist(DREES,2017).

4 Price setting for acute hospital care

Hospital context

TheFrenchhospitalsectorischaracterizedbyahighnumberofpublicandprivateproviders.Patientscanfreelychoosebetweenthemwithoutareferral.While90%ofthehospitalexpenditureisfundedthroughpublichealthinsurance,onethirdofthisexpenditureoccursinprivate-for-profithospitals.

Publichospitalsrepresent60%ofhospitalsand65%ofallacuteinpatientbeds.Theyhavethelegalobligationofensuringthecontinuityofcare,whichmeansproviding24-houremergencycare,acceptinganypatientwhoseekstreatment,andparticipatinginactivitiesrelatedtonational/regionalpublichealthpriorities.Theprivate-for-profitsectorrepresents25%ofallinpatientbeds,but45%ofsurgicalbeds.Themarketshareofprivatehospitalsdependsheavilyonthetypeofhospitalactivity:morethanhalfofallsurgeryandonefourthofobstetriccareareprovidedbyprivate-for-profithospitals.Theirmarketsharegoesuptomorethan80%insomeareasofelectivesurgery,suchaseyesurgery(cataractinparticular),earsurgery,andendoscopies.Incontrast,certaincomplexproceduresarecarriedoutalmostexclusivelybypublichospitals,forexampleinthecaseofburntreatments(92%)ortreatmentofpatientswithsurgeryofseriousmultipletrauma(97%).

Until2004,publicandprivatehospitalswerepaidundertwodifferentschemes.Ontheonehand,publicandmostprivatenot-for-profithospitalshadglobalbudgetsmainlybasedonhistoricalcosts,makinglittleadjustmentforhospitalefficiency.

74 Price setting and price regulation in health care

Ontheotherhand,privatefor-profithospitalshadanitemizedbillingsystemthatwasinflationarywithdailytariffscoveringthecostofaccommodation,nursingandroutinecare,andaseparatepaymentbasedonthediagnosticandtherapeuticprocedurescarriedout,withseparatebillsforcostlydrugsandmedicaldevices.Inaddition,doctorsworkinginprivatehospitalsarepaidonaFFSbasisunlikethoseworkinginpublichospitalswhoaresalaried.

Thedifferenceinpaymentbetweenpublicandprivatehospitalshasalwaysbeenasubjectofconflict.Publichospitalsconsideredglobalbudgetsasaninstrumentofrationing,whichstrangledthemostdynamichospitalsandwasinsensitivetochangingdemand.Privatehospitalsadvocatedthatglobalbudgetsrewardedinefficiencyandfairbenchmarking;theybelievedthattheywouldbemoreefficientandincreasetheirmarketshareunderactivity-basedpayment.Therefore,theintroductionofABP(tarification à l’activité,orT2AinFrench)in20053topayforacutehospitalserviceswasverywelcomedinitially.ThemajorobjectivesofABPweretoincreasehospitalefficiency,tocreatea‘levelplayingfield’forpaymentstopublicandprivatehospitals,andtoimprovethetransparencyofhospitalactivityandmanagement.TheinitialobjectiveofshiftingtoABPforfundingrehabilitationfacilitiesandpsychiatrichospitalshasbeenpostponedseveraltimesduetodifficultiesinimplementationandproblemsfacedintheacutesector.

Price setting in acute care hospitals: the DRG payment model

UnderABP,theincomeofeachhospitalislinkeddirectlytothenumberandcase-mixofpatientstreated,whicharedefinedintermsofhomogeneouspatientgroups(calledGHMinFrench,Groupe Homogène de Malades).TheclassificationsystemusedinFrancewasinspiredinitiallyfromtheUSHealthCareFinancingGroupclassification(HCFA-DRG)butadaptedtotheFrenchsystemandmodifiedregularlyovertheyears.TheGHMclassificationhaschangedthreetimessincetheintroductionofT2A,passingfrom600groupsin2004to2680today(in2018).Thecurrentversion(version11),introducedin2009,significantlycomplicatedtheclassificationwithfourlevelsofcaseseverityappliedtomostGHM,usinginformationonlengthofstay(LOS),secondarydiagnosesandage.

TheinstitutionresponsiblefordevelopingthepatientclassificationsystemandcalculatingpricesistheTechnicalAgencyforHospitalInformation(Agence technique de l’information sur l’hospitalisation,ATIH).ATIHwascreatedin2002andisanindependentpublicadministrativeinstitutionco-fundedbythegovernmentandpublichealthinsurancefunds.Ithasanadvisorycommittee,involvingrepresentativesofpublicandprivatehealthcarefacilities,whichmakesuggestionsbasedontheirexperienceswiththesystem.

3 Implemented progressively in the public sector between 2004 and 2008.

75Price setting and price regulation in health care

Definition of GHM tariffs

Theinformationforcalculatingprices(referencecosts)comesfromthehospitalcostdatabase(Etude nationale de coûts à méthodologie commune,ENCC),whichprovidesdetailedcostinformationforeachhospitalstayfromvoluntaryhospitals.Until2008,thecostdatabasecoveredonly3%ofpublicandprivatenon-for-profithospitals(about40).Thenumberofparticipatinghospitalshasincreasedslightlysince2008.In2018,theENCCcovered135hospitals(ofwhich52areprivate-for-profit)(ATIH,2017).

GHMreferencecostsareupdatedannuallybyATIHonthebasisofinformationfromthehospitalcostdatabase.However,thereisalwaysatimelagoftwoyearsbetweentheyearofthedataandtheyearofthepriceapplicationinhospitals.Forexample,hospitalcostsdatafromtheyears2013,2014,2015(three-yearaverage)wereanalyzedduringtheyear2016inordertodefineGHMpricesforhospitalpaymentsin2017.

GHMprices(tariffs)aresetatthenationallevelbasedonaveragereferencecostsbyGHMcalculatedseparatelyforpublicandprivatehospitals.Therefore,therearetwodifferentsetsoftariffs:oneforpublic(includingprivate-non-profit)hospitalsandoneforprivatefor-profithospitals.Moreover,whatisincludedinthepricediffersbetweenthepublicandprivatesectors.Thetariffsforpublichospitalscoverallofthecostslinkedtoastay(includingmedicalpersonnel,allthetestsandproceduresprovided,overheads,etc.),whilethosefortheprivatesectordonotcovermedicalfeespaidtodoctors(whoarepaidonaFFSbasis)orthecostofbiologicalandimagingtests(e.g.scanners),whicharebilledseparately.Theinitialobjectiveofachievingpriceconvergencebetweenthetwosectorsstartedin2010onabout40GHM(highlyprevalentbothinpublicandprivatehospitals)andpursueduntil2012,butwasabandonedafterwardsagainstferventcriticsfrompublichospitals(wherethetariffsarehigher).

Inprinciple,GHMpricesarenotadjustedtotakeintoaccount“unavoidablevariations”inthecostofdeliveringservices,butpublichospitals(andprivatehospitalsparticipatinginso-called‘publicmissions’)receiveadditionalbundledpaymentstocompensateforcostslinkedtoeducation,researchandinnovationrelatedactivities(MIGAC)andsomepublicmissions(activitiesofgeneralpublicinterestsuchasinvestinginpreventivecare,outreachingtounder-privilegedpopulations,etc.).Hospitalscanalsoreceivefundingfromregionalhealthagencies(agences régionales de santé,ARS)tofinanceinvestmentsforqualityimprovement.Thecostsofmaintainingemergencycareandrelatedactivitiesarepaidbyfixedyearlygrants,plusaFFSelementtakingintoaccounttheyearlyactivityofproviders.Finally,arestrictedlistofexpensivedrugsandmedicaldevicesispaidretrospectively,accordingtotheactuallevelofprescriptionsmade.

TheactualpricesperGHMarenotexactlyequaltoreferencecosts.TheyaredeterminedbytheMinistryofHealthtakinginto

76 Price setting and price regulation in health care

accounttheoverallbudgetfortheacutehospitalsector(ONDAMtargetexpenditure)andpublichealthpriorities.Inordertocontainthelevelofhospitalexpenditure,national-levelexpendituretargetsforacutecare(withseparatetargetsforthepublicandprivatesector)aresetbytheParliamenteachyear.Iftheactualgrowthintotalhospitalvolumeexceedsthetarget,pricesgodownthefollowingyear.Thegrowthofactivityvolumesisnotregulatedattheindividualhospitallevelbutatanaggregatelevel(separatelyforthepublicandprivatesector).Priceshavebeenadjusteddownwardsquiteregularlysince2006,sincethehospitalactivityvolumeshavebeenincreasingconsistentlyfasterthanthetargetsset.Furthermore,GHMreferencecosts(“raw”tariffs)aremodifiedinanopaquewaytointegratevariousobjectivessetbythegovernmentandtheSHIfundeachyearwhencomputingactualprices.Forexample,in2009,ATIHnotedthatGHMpricesweremodifiedtoadjustfortheincreaseintheadditionalbudgetsforspecific‘missions’,includingeducation,researchandinnovationrelatedactivities,thegrowthofexpendituresforadditionalpaymentsonexpensivedrugs,andnationalpriorities(forcancertreatmentandpalliativecare)aswellastheevolutionofoverallactivityvolumes.However,itisnotentirelyclearhowthesedifferentelementsinfluencedthepricesofdifferentGHM.

Globally,thismechanismappearstobesuccessfulincontainingoverallhospitalexpenditures,sincetheshareofhospitalexpendituresintotalexpendituregrowthhasdecreasedvisiblysincetheintroductionofABP(Figure7).Inrecentyears(2014/15),thehospitalsectormanagedeventounderspendwithrespecttothetargetsetbyONDAM.However,thismacro-levelregulatorymechanismhasitsdownsides(Or,2014).Itcreatedanopaqueenvironmentwhereitbecameverydifficultforhospitalstopredicttheirbudgetsituationforthenextyear,sincepriceschangeeveryyearasafunctionofoverallactivity.ThelackofinformationonthespecificobjectivespursuedwiththepaymentpolicyalsocreatedfrustrationandresentmentaboutT2Aattheproviderlevel.Intheabsenceofclearpricesignalsandlackofcostdataforbenchmarkinghospitals,providersappeartobeconcernedmainlyonbalancingtheiraccountsbyincreasingtheiractivity.

77Price setting and price regulation in health care

Figure 7 Annual percentage increase in hospital expenditures

6

5

4

3

2

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2000/05 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17

Perc

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nnua

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wth

Source:DREES,2018.

Despiteapositivetrendinproductivityofpublichospitalssince2004,withastrongriseincase-mixweightedproduction,thereisalsoevidenceofpatientselectionwithincreasedspecializationintheprivatesectorandinduceddemandforsometypesofsurgery(Oretal.,2013;Studer,2012).Moreover,externalcontrolscarriedoutbySHItoidentify“unjustified”billingofservicesshowthatup/incorrectcodingwasanissue,atleastintheinitialyearsofABP.Between2006and2009,threequartersofhospitalswereauditedatleastonce,and,amongthese,halfwereauditedmorethanonce.In2006,morethan60%ofinpatientstays(morethan80%forambulatoryepisodes)hadsomekindofcodingerrororinconsistencyinproceduresbilled(CNAM,2009).Ifup-codingorincorrectcodingisdetected,hospitalshavetoreimbursereceivedpayments.Inaddition,theymayhavetopayfinancialpenaltieswhichcangoupto5%oftheirannualbudgets.Therevenuesrecoveredfromthesepenaltiesamountedto€51millionin2008and€23millionin2010(Daudignyetal.,2012).Overall,DRG-basedpaymentaddressedsomechronicproblemsinherenttotheFrenchhospitalmarketandimprovedtheoveralltransparencyofinformationconcerninghospitalactivity.Nevertheless,italsocreateditsownproblems.

78 Price setting and price regulation in health care

Figure 8 Hospital expenditure growth: Price versus volume effect

Public sector

-2

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Source:DREES,2018.

Today,itislargelyrecognizedthatABPprovidesincentivestodevelophospitalactivity,sometimesbeyondwhatismedicallynecessary,raisingquestionsabouttheappropriatenessofhospitalizationsforcertainproceduresandconditions(Figure8).AsurveyoftheFrenchPublicHospitalAssociationshowedthat,accordingtohospitalphysicians,one-quarteroftheproceduresandmedicaltestscarriedoutinhospitalsweremedicallyunjustified(Fédération hospitalière de France,2012).Furthermore,thereisagrowingconsensusthatABPdoesnotfavorcooperationbetweendifferentprovidersorbetweendifferentserviceswithinthesamehospitaltoassurecarecoordinationandaholisticapproachincareprovision.

In2016,aquality-basedpaymentscheme(Incitations financières à l’amélioration de la qualité,IFAQ)wasintroducedtoencourageinvestmentinquality.Amodestproportionofproviders’incomeislinkedtotheachievementofnationallysetobjectivesconcerningabatteryofqualityindicators(mostlyofcareprocessandstructure/organization,butalsopatientsatisfactionin2018).TheIFAQpaymentframeworkcancoverupto1.5%ofahospitals’annualincome,andthispercentageisexpectedtoincreaseincomingyears.ThecurrentgovernmentisalsoplanningtoreducetheshareofABPinhospitalpayment,withseveralpropositionsforbundlingpaymentsbeyondacutehospitalreimbursement(especiallyforchronicallyillandmulti-morbiditypatients)andincluding

79Price setting and price regulation in health care

rehabilitativeservices.However,thismaybemoredifficulttobringaboutthaninitiallythoughtduetothelackofrobustcostdataacrossproviders.

Using prices to regulate hospital activity

Inparallel,DRGtariffsareusedincreasinglytoinfluencehospitalactivityandincentivizebetterpractice.Intwoareas,priceswereusedactively:fordevelopingambulatorysurgeryandforcontrollingcaesareansectionrates.Thepricesofambulatorystaysarealignedwithnon-complicatedovernightstaysformostcommonproceduresinordertoencouragehospitalstoinvestinambulatorysurgery.Increasingambulatorysurgeryrateshasbeenalong-termobjectiveforthehospitalsector,butitisonlyrecently,since2011,withpriceadjustmentsthatrateshavebeenpickingup(from44%in2011to54%in2016).Asforcaesareansections,tariffsforuncomplicatedprogrammedcaesareansectionshavebeenkeptrelativelylowinrecentyearstomakesurethattheprofitmarginsfortheseoperationsareverylow.Currently,thereissomediscussiononidentifyingotherareaswherefinancialincentivesmaysupportgoodpracticeoronsanctioningunwarrantedhospitalizations.

Since2014,theMinistryofHealthhasintroducedavolume-pricecontrolmechanismattheindividualhospitallevel.Foranumberofhighvolume/fastgrowingDRGs(includingkneeprosthesisandcataractsurgery),theMinistrysetsanationalrateofactivitygrowth.Ifahospital’scaseload(foragivenDRG)growsfasterthanthethresholdset,thetariffoftheconcernedGHMgoesdownby20%forthehospital.Thereisnotenoughinformationontheimpactofthispolicyonhospitals,butaveryrecentnotefromtheMinistryofHealthannouncedthattherewillbefurthermeasuresforreducinginterventionsconsideredas“lowvalue”care.

Payments for acute psychiatric hospital care

TheABPsystemhasnotbeenextendedtoacutepsychiatrichospitalcare.Thisisrelatedtothedifficultiesinestablishingadiagnosisformentalhealthproblems,thediversityintheformsofpsychiatriccareprovided,andthehistoricalterritorialorganizationofmentalhealthcareinFrance.Inaddition,thereisnoconclusiveexperienceoftheDRG-basedpaymentsystemforacutementalhealthcareabroad(Denketal.,2011;Wolffetal.,2015;Linetal.,2016;CNAM,2018d).Thepsychiatriccareinpublicandnon-profithospitalsisthereforefundedthroughanannualprospectiveglobalbudgetwhichispaidbySHIandallocatedbyregionalhealthagenciesonthebasisofhistoricalcostsadjustedbytheexpectedannualgrowthrateofhospitalspending.TheglobalbudgetsaredefinedintheframeofODAM,whichisasub-objectiveofONDAMforhospitalsnotfundedthroughtheactivity-basedmodel(Cour des Comptes,2011).Theseglobalbudgetsincludecapitalinvestmentswhichdonotbenefitfromspecificdedicatedfunding.Paymentstofor-profithospitalsarebasedonpredetermineddailyrates

80 Price setting and price regulation in health care

fixedaccordingtothetypeofcareprovided(forinstancefull-timeorpart-timehospitalization).TheseratesareadjustedyearlyattheregionallevelbytheARSinlinewiththenationalexpendituretargetssetbyONDAMforhospitalcare(Cour des Comptes,2011).

Manysuccessiveinstitutionalreportshavecriticizedthesefundingmechanismsforacutepsychiatrichospitalcareandsuggestedaglobalreformofthepaymentmodel(PielandRoelandt,2001;Cour des Comptes,2011).Plannedevolutionsincludeanadjustmentoftheglobalbudgetsforpublicandnon-profitacutepsychiatrichospitalsonthecharacteristicsofthepopulationserved,includingtheirsocio-economiccharacteristics,from2019onwards.Adjustingbudgetsonindicatorsofqualityofcare,similarlytowhatisdoneforacutecarehospitals,andharmonizingthepaymentmodelsofthepublicandprivatefor-profitsectorarealsolistedasfuturereformsbythegovernment(TaskForce“Réforme du financement du système de santé”,2019).

5 Price setting for rehabilitation and long-term care (LTC)

Inpatient rehabilitation services

Rehabilitationininstitutions(soins de suite et de réadaptation,SSR)werefundeduntil2017basedonamodelsimilartotheoneforacutepsychiatrichospitalcarethroughanannualprospectiveglobalbudgetforpublicandprivatenon-profithospitalsandthroughadailyfixedrateforprivatefor-profithospitals.Since2017,theglobalbudgetshavebeenadjustedtotakeintoaccountthevolumeandcase-mixofthepatientstreated.Since2010,apatientclassificationsystemapplyingthelogicofhomogeneousmedicalresourcegroupsasinDRGshasbeenused.Thereareabout750groupscalledGME(“groupes médico-économiques”)forservicesprovidedintheseinstitutions.ReferencecostsfordifferentgroupsofpatientshavebeenestimatedandupdatedannuallybyATIH.TheprocessoffixingthesereferencecostsissimilartotheonefortheDRGtariffsinacutecarebasedonacostdatabaseofasampleofvoluntaryhospitals(seesection4.2).SinceMarch2017(i.e.sevenyearsafterthedevelopmentofthefirstclassificationandcostsinSSR),thefundingofrehabilitationfacilitieshasbeenmixed:90%ofthefundingiscalculatedbyformermodalities(globalbudgetorfixeddailyrate),while10%isactivity-basedusingGMEasreferencetariffs.

Long-term residential care for elderly

Olderpeoplewhoneedmedicalattentionorhelpwiththeactivitiesofdailylivingiftheycannotlivealoneathomearelookedafterinfacilitieswhicharemedicalnursinghomesfordependentelderlypeople(Etablissement d’hébergement pour

81Price setting and price regulation in health care

personnes âgées dépendantes, EHPAD).ThepublicfundingofthesefacilitiescomesmainlyfromSHIconcerningthecostofhealthcareandfromlocalauthorities(départements)andthenationalfundforautonomy(Caisse nationale de solidarité pour l’autonomie,CNSA)tofinancepersonalandsocialcare.

TheoverallamountforresidentialcarefundedbySHIissetannuallybyaministerialorder.Itcorrespondstothemedico-socialfractionofthenationalhealthinsuranceexpendituretarget(ONDAM).Thisamountwasabout€9billionin2017forthelong-termcareoftheelderly.ThisfundingisentrustedtoCNSA,whichisresponsibleforredistributingthefundingtotheARS.ThemissionofARSistoregulatethesupply(authorizationtoopenafacility,numberofplaces,etc.),controlthequalityofcare,andnegotiatethehealthcareportionofthefundinginnursinghomes.

Historically,thebudgetwasnegotiatedaccordingtothevolumeobjectivesoffacilitiesandonthebasisofpastexpenditures.Inrecentyears,therehasbeenashiftfromcost-basedfundingtopayments-basedfundingontheactivityandcharacteristicsofthecarerecipients.Today,facilitiesfordependentolderpeople,whetherprivatefor-profit,privatenon-profitorpublicarepaidbyathree-parttariff:acarepackage,along-termcare(ordependency)bundleandanaccommodationfee(Bonne,2018).

The care package,financedbytheSHIfund,iscalculatedforeachfacilityaccordingtoasyntheticindicator,calledtheISO-weightedcaregroup(GMPS),whichcorrespondstotheaveragecareneedsanddependencylevelofpeoplelivinginthefacility.Careneedsaremeasuredbythecoordinatingdoctorofthefacility4usingaclassificationcalled“pathos”,whichidentifies50clinicalconditionswith12profilesofcarerequiredbytheseconditionsconstituting238couplesof“condition-profiles”(CNSA,2017).Foreachofthesecondition-profiles,eightresourcegroupswereidentified(physician,psychiatrist,nursing,rehabilitation,psychometrics,biology,imagingandpharmacy),whichdefinethelevelofcareresourcesrequired.Forhealthprofessionals,thiscorresponds,forexample,tothetimerequiredforpatientswithagivenprofile.Theaverageresourcelevelrequiredforeachofthe238coupleswasdefinedbyspecialists(geriatricphysicians)andreportedintermsofpointspercostitem.Forexample,forthecouple“heartfailure”withtheprofile“closemonitoring”,thespecialistsestimatedthatitrequires13minutesofgeriatriciantimeaday,36minutesofnursetime,etc.Theaveragepathosscore(PMP)isthesumofthepointsofcarerequiredineightresourcegroupsweightedbyacoefficientdependingonresourcegroupsexpressedonaverageperindividual.Thecarebundleisalsoadjustedbythedependencylevel,whichiscalculatedbytheAGGIR(GerontologyAutonomyandIso-ResourceGroups)model,whichassessestheautonomyofapersonforcarryingessentialdailyactivities(CNAM,2008).Thedependencyscore(GIR)isbasedon10variablesofphysical

4 This evaluation has to be validated by two other external medical doctors appointed by the local county (département) and the regional health authority.

82 Price setting and price regulation in health care

andmentalactivities(coherence,orientation,toilet,dressing,food,etc.)andsevenvariablesofdomesticandsocialactivities(cooking,household,transport,etc.).

TheamountofcarepaymentforeachfacilityistheaverageGMPS score5multipliedbythevalueofthepoint.ThevalueofthepointisdefinedbytheMinistryofHealth(atthenationallevel)basedonONDAMformedico-socialfacilities.

The long-term/dependency bundlefinancesthecareprovidedtothemostdependentresidentsinhelpingthemwiththeactivitiesofdailyliving(costofthecaregivers).ItiscalculatedaccordingtotheGMP(averageGIRscore)ofthefacilityandthevalueofthedepartmentalGIRpointfixedbythecountycouncil(Conseil départemental).ThevalueofthedepartmentalGIRpoint,thatis,theleveloffundingbythedépartement,variesgreatlybetweendépartements,rangingfrom€5.7intheAlpes-Maritimesto€9.4intheSouthofCorsicain2017asafunctionoflocalpolicyandincome.

Accommodation feesarepaidentirelybytheresidents.Theratesvarydependingonthe“standing”ofthefacility(comfortoftherooms,qualityofthecooking,etc.),butalsoontheagreementofthefacilitytoreceivesocial/publicaid.Onlyprivatefor-profitfacilitiesarecompletelyfreeinsettingtheaccommodationprices,becausethemajorityofnon-profitfacilities,whetherprivateorpublic,areeligibleforpublicsupportandcannotaskforahigheraccommodationpricethantheonesetbythedépartement(basedonpastdeclaredcostsbythefacilities).

Fordependentelderlypeoplelivingathome,medicalandsocialcareservicesaregenerallyprovidedandpaidseparately.HealthcareisfinancedonthebasisofpricesfixedbytheSHIfundwithafeeforvisits,proceduresandmedicaldeviceswiththepossibilityofbalancebilling.Thepersonalandsocialcareservices(helpwithdailyliving,meals,etc.)areofferedbythepublic,privateorassociativesectors.Pricesarenotregulatedandvaryaccordingtosupplyanddemand.Thereis,however,areferencetariffusedbydépartementstocalculatetheamountofthefinancialaid(APA)fordependentolderpeople(notmeantested,butdependingonthe“need”evaluatedbythedépartementusingthegridGIRassessingautonomy).Thesereferenceratesvaryfromonedépartement toanotherfrom€13to€24perhour.Thenursingcareathomeismostlyprovidedbyself-employedFFSnurseswhoarepaidbasedonpricessetbytheSHIfund.

5 The GMPS score of a facility is the average pathos score (PMP) plus the average GIR score of all residents.

83Price setting and price regulation in health care

Annex 1 Indicators taken into account for bundled payments to physicians

Section 1: organization of office practice

Availabilityofasoftwarecertifiedbythenationalhealthauthoritytohelpwithprescriptionsandcompatiblewithsharedelectronicmedicalrecords

Availabilityofasecurehealthmessagingservice

Displayofpracticehoursinthehealthdirectory

Availabilityofthelatestversionofsoftware(Sesam-Vitale)forbillingelectronically

Rateofelectronictransferssuperiororequalto2/3ofallconsultation/prescriptionformsissued

Section 2: involvement in services for patients within the office practice

Capacitytocodemedicaldata

Involvementincoordinatedcarepathways

Specificservicesofferedtopatients

Managementandtrainingofmedicalstudents

Rateofdematerializationreachedonanumberofteleservices

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