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French Public Health Insurer Unveils Plans to Contain Healthcare Deficit
25 Jun 08
A set of measures aimed at shaving 3 billion euro (US$4.7 billion) off of France's healthcare bill has caused a general uproar in the country.
Global Insight Perspective | | Significance | The French public health insurer CNAM has unveiled a raft of proposals to bring the Social Security scheme back into the black. The most controversial measures to this effect are the attempt to shift the financial burden of some drugs onto private insurers and the possibility of a tightening in the list of chronic diseases qualifying for full public reimbursement. Additional measures include medicine and medical-exam price cuts. | Implications | The proposal should save the CNAM about 3 billion euro (US$4.7 billion), of which 250 million would come from the partial reimbursement de-listing of supplementary drugs. Although the government has yet to agree on it, the set of measures was met with general consternation as the public sees this as a possible end to the principle of "national solidarity." | Outlook | The government will carefully evaluate the set of measures as it is keen to erase the Social Security's predicted 4.1-billion-euro deficit by 2011. Nevertheless, it is likely that the most controversial measures will be left out of the proposal for now as they may very well be counterproductive and shift prescribers' behaviour to more expensive but fully reimbursed medicines. On the other hand, medicine and exam-price cuts, which have received little media attention, are likely to go ahead easily. |
The director of the French national public health insurer (CNAM), Frédéric Van Roekeghem, has unveiled a set of proposals aimed at saving the public body approximately 3 billion euro (US$4.7 billion). The most controversial measure is the partial reimbursement de-listing of supplementary medicines for patients suffering from chronic diseases such as cancer, HIV/AIDS, diabetes, rheumatoid arthritis, cardiovascular disease, Alzheimer's and Parkinson's. Supplementary medicines are prescribed along first-line treatments to improve patients' quality of life and include drugs such as anti-emetics, laxatives, and gastric reflux treatments. Under the proposal, the reimbursement of these medicines by the public health insurer would be cut from 100% to 35% and mutual health insurers (private health insurers) would be asked to cover the remaining reimbursement costs. This measure is expected to save the public health insurer 250 million euro in 2009. Roekeghem has also proposed a re-examination of the list of chronic diseases with the goal of tightening it. As it stands, the list is made up of 32 conditions, and patients officially diagnosed with those enjoy 100% reimbursement of their first-line and supplementary medications. Additional measures unveiled yesterday include a price decrease for radiology and lab exams as well as price cuts on patented drugs with generic competition. Speaking on national public television last night, French Health Minister Roselyne Bachelot-Narquin stressed that her top priority was to reduce the country's public healthcare deficit. The government will therefore pay close attention to the proposals and accept or reject them by 15 July. Bachelot-Narquin also reaffirmed her commitment to the principle of "national solidarity" and stressed that patients suffering from chronic diseases will not have to make co-payments for their supplementary medicines as the reimbursement differential will be covered by mutual insurers. She went on to promise that premiums for private insurances will not go up as a result, since the shift will be accompanied by a 0.03% drug-price cut. In the case of those patients without supplementary insurance, the public insurer will maintain 100% reimbursement on those medicines. An estimated 7-8% of people do not have supplementary health-insurance cover in France. In France, 7.7 million people officially suffer from chronic diseases, at an annual cost of 8,700 euro per person. Chronic diseases currently account for 64% of the public insurer's expenditure, up from 50% in 1992. With the ageing population, an estimated 12 million people will be affected by chronic diseases by 2015. Outlook and implications The pressure is mounting to contain the deficit of the Social Security scheme in France. The scheme, which covers public healthcare expenditure, is forecast to run a 4.1-billion-euro deficit in 2008, down from 4.6 billion in 2007. There have been multiple pledges to balance the scheme's books, a target that the government now hopes to achieve by 2011. Interestingly, the proposals are bringing the country one step closer to a two-tiered healthcare system. Although the government is adamant that private insurers will cover the reimbursement differential, the latter have yet to agree to this. In addition, the level of private cover depends on the premiums paid by the public, raising the possibility that some patients with chronic diseases could be left out in the cold if they can only afford lower premiums and reimbursement on supplementary medicines is not made part of the basic package. It is also hard to imagine how the government will guarantee that private insurance premiums will not rise. Although the shift from public to private reimbursement should be accompanied by drug-price cuts, private insurers will be keen on maintaining or expanding their margins. If accepted, Roekeghem's proposal would give them a very public opportunity to do so, which would result in more of the cost of healthcare being pushed on to patients (France: 17 December 2007: "Franchises" Drug Co-Payment System Rubber-Stamped in France). While the government is trying to break free from the French socialist model for healthcare provision, the public is emotionally attached to it and the proposals have therefore been met with a general uproar. Given the general attachment to full coverage for chronic diseases, if implemented, these measures could be counterproductive and prompt healthcare practitioners to prescribe more expensive supplementary medicines among those that would still be covered by the public health insurer. It could also result in patients being inadequately treated for their disease and the Social Security scheme paying the price for what might result in false economies further down the line. The likelihood that the set of measures will be accepted in block is relatively low. Realistically, the more controversial measures of the proposal may be left out for now and the government may explore further avenues to cut healthcare spending. However, if the government decides to go ahead and shift reimbursement costs onto private insurers and restrict the list of chronic illnesses, this would open the door to further similar measures in the future. It would in the end only be another attempt by the French government to bring the message home that extensive free public healthcare is not realistically affordable.
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