European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of France

3.4 Out of pocket payments

Of the 26.9% share of total health care expenditure not paid/reimbursed by SHI, VHI financed a 13.9% share and patients a 7.5% share in 2011 (WHO, 2013). SHI coverage varies across sectors and thus OOP expenditure on health varies inversely with the level of SHI coverage: 39.6% of OOP expenditure is accounted for by medical goods, 8.2% by hospital care and 35.7% by payments to self-employed health professionals (DREES, 2012). Overall, the level of charges left to the patient is 23.3%, which is often covered by VHI.

In the health and social care sector, OOP payments for residential long-term care services have steadily increased and in 2012 averaged €2892 per month (ATIH, 2014), raising concerns about equity in access to these services.

3.4.1 Cost-sharing (user charges)

Patients are directly responsible for:

  • the cost of health care not included on one of the positive lists covered by SHI (such as care provided by psychotherapists or psychoanalysts);
  • deductibles for consultations, prescription drugs, nursing care and medical transportation up to an annual limit;
  • co-payments (such as the hospital catering fee);
  • co-insurance (difference between the statutory tariff and the amount reimbursed by SHI);
  • additional co-insurance of 40% for care outside of the coordinated care pathway; and
  • extra-billing charges by certain professionals.

Exemptions, deductible caps and programmes to facilitate access to VHI help to offset these user charges (Table3.8; see also section 3.3.1). Nonetheless, extra-billing is frequent, and half of the population pays at least one extra-billing charge per year. These charges vary widely in number and amount across sectors. In 2010, extra-billing by doctors practising in Sector 2 accounted for €2.5 billion, mostly attributable to specialists (€2.1 billion), compared with €18.4 billion reimbursed for doctors’ fees excluding extra-billing (CNAMTS, 2011). In the inpatient sector, OOP payments are significant for patients not covered by VHI, ranging from a few hundred to a few thousand euros (HCAAM, 2013c). However, the medical device sector accounts for the largest share of extra-billing charges. While VHI covers approximately 50% of these charges, coverage varies greatly depending on the VHI contract and the medical device in question.

3.4.2 Direct payments

Since its origins, SHI has been based on the principle that a person consulting a doctor in the ambulatory sector directly pays for the service and is thereafter reimbursed by SHI and, usually, by VHI. Since the 1970s, exceptions have been carved out for the most expensive care as well as for low-income households (beneficiaries of CMU-C, ACS and AME), and currently 35% of ambulatory care is subject to third-party payment (i.e. the health professional receives payment from SHI, and VHI, rather than from the patient). Development of electronic billing since the early 2000s has helped to reduce the delays for reimbursement. Nonetheless, the existence of direct payments is seen as a barrier to equity in financial access to health care, and the government is seeking to universalize third-party payment, as in other countries with SHI systems, including Germany, Austria and the Netherlands (IGAS, 2013b). The planned Health Reform Law will include the generalization of third-party payment among its provisions (see section 6.2).

3.4.3 Informal payments

While certain doctors are legally permitted to bill in excess of official tariffs (see section 3.7.2), informal payments are uncommon in France. Doctors engaging in abusive practices, including insisting on cash payment, are subject to disciplinary sanctions. Nonetheless, a 2014 survey by a collective of nongovernmental organizations acting for patient rights found that 5% of French patients had been confronted with a request by a health professional for an “under-the-table” payment, with patients over age 65, retired or chronically ill more frequently facing such requests (Collectif Inter-associatif sur la Santé, 2014).

Since July 2016, third-party payment (TPP) is feasible for statutory health insurance (SHI) beneficiaries who benefit from 100% coverage of the statutory tariffs. Starting from 1 January 2017, TPP becomes a right for those beneficiaries (around 11 million individuals), including patients covered by the long-term illness programme (ALD) and pregnant women. Until now, TPP was limited to patients with low incomes or in a precarious situation and to patients suffering from work-related illnesses or injuries.

This measure, which is part of the 2016 Health Reform Law (Loi n°2016-41 du 26 janvier 2016 de modernisation de notre système de santé) also introduces the possibility for health professionals to offer TPP to all beneficiaries for the part reimbursed by the SHI (as well as for the part reimbursed by the voluntary health insurance). This is one of the progressive steps to achieve the extension of TPP to all SHI beneficiaries by the end of November 2017. This is particularly relevant for a country where a quarter of the population forgoes health care due to financial reasons.

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