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“Decreasing the benefit package is one means of decreasing the financial burden on SHI [Social Health Insurance]. Of all health care goods and services, drugs were the most affected by this type of measure. Between 1990 and 2009, prescription drug sales in France multiplied 2.5 times, with SHI covering approximately 75% of the total (Cour des comptes, 2011b). The steady increase in pharmaceutical expenditure has led to a series of measures aimed at limiting the usage of certain drugs and/or reducing the cost for SHI. Cost-containment measures have included increasing patient contributions (often covered by VHI), either by de-listing the drugs completely or reducing the rate of SHI coverage, reducing drug prices and encouraging generic substitution. Economic evaluation is the newest tool in the cost-containment policies.

“De-listing drugs has proven to be politically sensitive, as revealed by the history of de-listing since the late 1990s. In certain cases, drugs with insufficient SMR were subject to lower prices or reimbursement rates or even left at a 65% rate rather than being de-listed. A provisional coverage rate of 15% was instituted for certain drugs as an interim step towards de-listing in 2008. In 2010, the coverage rate for drugs with weak relative SMR decreased from 35% to 15%, and in 2011, the rate for drugs with moderate SMR was reduced from 35% to 30%. An additional 26 drugs were de-listed in 2011, including 17 that had been covered at 15%. The Minister in charge of Health announced in January 2011 that all drugs with an insufficient SMR would be de-listed or subject to a systematically motivated decision if coverage was to be maintained. However, to date there has been no decree authorizing this alternative coverage procedure, and the left-wing government elected in 2012 has not put this measure forward since then.”

Source: Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernández-Quevedo C. France: Health system review. Health Systems in Transition, 2015; 17(3): 1–218.

“Strict control of tariffs was applied, notably to the price of drugs but also to other type of service such hospital remuneration, medical devices and professional tariffs. As a result of tight control of doctors’ tariffs, extra-billing, which is not covered by SHI, was permitted starting in the 1980s for certain categories of doctor (see Sector 2 doctors; section 3.7.2). However, extra-billing in some specialties has significantly increased OOP payments, thereby impairing access in some areas where extra-billing is the rule (e.g. gynaecologists in Paris). For this reason, policies to reduce extra-billing were developed starting in 2013.”

Source: Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernández-Quevedo C. France: Health system review. Health Systems in Transition, 2015; 17(3): 1–218.

“Extra-billing is permitted for doctors practising in Sector 2, which includes 42% of specialists and 11% of GPs. In an effort to discourage excessive extra-billing, a “carrot and stick” approach was taken in a 2012 amendment to the collective bargaining agreement between SHI and physician unions. Since 2013, Sector 2 doctors may be subject to sanctions for excessive extra-billing, defined as fees in excess of 150% of official SHI tariffs. In addition, a voluntary three-year “Access to Health Care” contract (contrat d’accès aux soins) provides Sector 2 doctors with incentives to freeze their fees and average rate of excess billing at 2012 levels and to perform a share of their services at statutory tariff levels. The incentives include social and fiscal advantages and access for Sector 2 specialists to the €2 higher statutory tariffs of Sector 1 doctors. Patients consulting doctors who have signed the agreement also benefit from improved coverage of the services by SHI. However, from April 2015, patients of non-signatory doctors may be exposed to increased OOP costs under a decree that places a ceiling on the amount of extra-billing that may be covered by VHI contracts (125% of official SHI tariffs in 2015–2016 and 100% thereafter).

“The average rate of extra-billing by doctors practising in Sector 2 decreased from 56.9% in 2011 to 56.3% in 2013, marking the end of nearly uninterrupted increases in extra-billing since the 1980s. One explanation is fear of sanctions for excessive extra-billing. The financial crisis may also been a contributing factor, as doctors responded to the reduced purchasing power of their patients.”

Source: Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernández-Quevedo C. France: Health system review. Health Systems in Transition, 2015; 17(3): 1–218.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.

Page last updated Feb. 2, 2023 by Doug McVay, Editor.