Rationing health care in France.

Since the Plan Juppé (1995), many facets of the French health care system have been the target of new legislative measures. This paper discusses the main features of the financing and provision of health care services, and focuses on issues related to priority setting and rationing. For more than 20 years, successive but systematic changes have been implemented. Most changes and measures affected the demand and supply of health care services, as well as their prices. Attempts to control demand focused mainly on the increase of user charges (ambulatory care as well as the hospital sector). Control over the volume of supply consisted, for the most part, in limiting the number of health professionals and restricting hospital beds. As far as payment is concerned, the French public authorities had set a general system of administrative prices (negotiated fees for private practice physicians, pharmaceuticals and other medical goods) and implemented global budgets for public hospitals. Among the new features designed in 1996, which target both cost-containment and quality of care, we emphasise the Parliament's involvement in setting national expenditure targets for sickness funds, the experimentation with a gatekeeper-like system (médecin référent), the development of practice guidelines and quality controls through the accreditation of hospitals. As the 1998 Eurobarometer Survey clearly shows, none of these reforms is easy to implement; they will take time to be accepted and will need physicians' support to succeed.

Health care under French national health insurance.

Several elements of the French health system--the predominance of office-based medical practice, the mix of private and public hospitals, the use of patient cost sharing, direct payment of physicians by patients, and financing derived from payroll taxes--closely resemble aspects of the U.S. health system. There are four major differences between the two systems: the French system covers more than 99 percent of the population; the prices of health services in French are lower than in the United States; the volume of most services is higher than in the United States; and French health care spending per capita is lower than in the United States. Recently enacted and proposed reforms in France likely will strengthen existing health spending targets and utilization controls.

Health services utilization and physician income trends.

Statistics from several Organization for Economic Cooperation and Development countries on consumption and cost of health care services, physician workload, and physician earnings are presented. Data are analyzed according to type of physician payment used: fee for service, per case, capitation, or salary. Incentives theoretically embodied in each payment method are often offset by other factors--scale of charges, patient out-of-pocket payment, and patient access or physician activity restrictions. Moreover, the impact of payment method on use appears to be weaker than the impact of such factors as population morbidity, national health insurance, professional ethics, and medical technology.

Ambulatory care: France, Federal Republic of Germany, and United States.

This study describes the results of a comparison of ambulatory medical care data for France, the Federal Republic of Germany (FRG), and the United States of America (U.S.). Data for this comparison were derived from independent national sample surveys in ambulatory care systems of the three countries in 1981-83. The French data set resulted from a sample of physicians who had been asked to document all patient-physician contacts for a specified 3-day period during 1982-83. The FRG survey of patient-physician contacts was performed in the fourth quarter of 1981 and the first quarter of 1982. Sample physicians reported for a sample of patient-physician contacts during two consecutive weekdays, the reporting periods being spread across the two calendar quarters in a balanced fashion. Survey physicians had been drawn at random from almost all ambulatory care specialties. U.S. survey data were obtained through a random sample of physicians reporting for a sample of their patient-physician contacts for a whole week, with the reporting weeks being spread across the whole year of 1981. Because regular office hours generally do not take place on weekends, Sundays were excluded in the French survey; in the FRG survey Saturdays and Sundays were excluded as reporting days. Although the French and the U.S. study universes consisted of almost all physicians practicing ambulatory medical care in the respective countries, the FRG physicians were drawn from five regions of the country systematically selected to represent the Federal Republic of Germany with respect to demographic population characteristics and physician specialty distribution. The universes of physicians and patient-physician encounters of the three national studies varied according to the ambulatory medical care systems of the respective countries. Data sets for this international comparison were derived from the respective national studies by selecting personal patient-physician contacts (in the physician's office or in the patient's home--referred to as "encounters") with eight physician specialties (general practitioners, pediatricians, obstetricians/gynecologists, internists, psychiatrists/neurologists, dermatologists, ophthalmologists, and otorhinolaryngologists). Patient variables used in the international comparison are patient age, sex, visit status, reason for encounter, and disposition. Yearly rates of personal patient-physician encounters in ambulatory medical care were estimated. Crude and age-sex standardized rates were computed for selected patient and physician characteristics.

Hospital use in France and the United States.

This report presents national statistics on hospital use from the U.S. National Hospital Discharge Survey conducted by the National Center for Health Statistics and the national survey of hospitalization conducted by CREDES, Centre de Recherche d'Etude et de Documentation en Economie de la Santé, previously the Medical Economics Division of CREDOC. The use statistics compared between the two countries include rates and percent distributions of discharges and days of care and average lengths of stay. These statistics are shown by sex, age, diagnostic category, and other hospital and patient characteristics. The similarities and differences between the two countries in population characteristics, causes of death, health care systems, and hospital systems are also described.

Methods for the evaluation and analysis of health expenditure.

PIP: The purpose of health expenditure evaluation is to give an overall picture of the amounts spent for the functions of the health system; it also allows the analysis of the financial flows between the financiers, producers and consumers of the health system. Principles of evaluation include: monetary evaluation (market prices); avoidance of double accounts; quick communication of data; use of all available reliable statistics; use of rough estimates rather than leaving blanks in tables. Information already available can be used. Statistics also should be collected from financing bodies, providers of medical care, sample surveys, and general sources. Many statistics cannot be used directly but must be processed, adjusted, or broken down. In order to analyze information for health services management, one must ask: who is financing the consumption of medical care, and what is the trend of medical expenditure by sector or activity? Over time, summaries should be used to analyze trends. At the macrolevel, structural trends can be compared, such as demographic factors, gross economic product, inflation, price of medical care, volume of medical care, and contribution of prices and volumes to increases in expenditures. Causes of these trends include factors such as changes in collective financing and developments in the health care system. A brief analysis of the trends in final medical consumption expenditure in France shows 3300 francs per person expended in 1979, (7.3% of the GNP in 1979). Tables for France show: type of expenditure; type of financing in 1979; medical expenditure as a % of the gross domestic product, 1950-1980; and type of financing, 1950-1978. Hospitalization has accounted for an increasing proportion of medical expenditure in France, reflecting improvement in quality of services offered by hospitals. Public financing is shown to be increasing in France.^ieng