The evolution of healthcare funding in France

Funding is one of the most substantial tools for the transformation of a health system. The French healthcare system is characterized by highly variable funding model based on the care sector. In order to contain costs smoothly, the authors state that the transformation of the financing should happen in a way that it will encourage actors to work on prevention, ensure a higher standard of quality of care, seek greater appropriateness of care and be more efficient. The authors say that their report advocates a gradual change in funding patterns over the next three years by offering as a medium-term strategy and that it is consistent with the transformation supported by the recent opinion of High Council for the Future of Health Insurance (HCAAM; Opinion of 24th of May 2018). Immediate measures will be implemented by the end of 2019 when the task force will introduce the steps to be implemented in 2020 and 2021. These measures will intervene in three different domains.

Domain 1 – pricing of hospital care

Measure 1 - relevance-based funding

• The current system does not prevent the financing of irrelevant acts. The regions differ in procedures performed
• The goal is to target the regions in which a particular procedure is performed much more than the national average (more than two times the standard deviation). These departments in these regions would be financed on a flat-rate basis for a part of these activities, and the rest will be paid on the GHS (group of homogenous stay) base but divided by 2
• This will directly increase the quality of care delivered. The patients will also avoid post-operative risks (and other risks related to the performance)            

Measure 2 – Quality financing

• The current pricing system should be complemented with incentives to improve the quality and appropriateness of care. Indeed, productivity gains in institutions, in the context of growth in activity and resource constraints, can be obtained at the expense of quality of care, which should not happen
• Quality indicators will be introduced, upon which a substantial part of the funding will be based. Furthermore, accompanying measures which improve quality will be provided to the healthcare facilities. Lastly, the results of the healthcare facilities will be transparent and available to the public. These will be introduced to only MCO, SSR and HAD sectors in 2019, but will gradually be extended to all areas.
• The patients will receive higher-quality care, and the coordination between the primary and hospital care will improve

Measure 3 – Funding packages for chronic diseases

• The objective is to introduce funding packages that will encourage comprehensive care for patients suffering from chronic diseases. This will be coordinated by various actors on a flat-rate basis. The measure will promote the prevention, but also coordination of the hospitals and primary care facilities, which will lead to fewer hospitalizations due to complications. In 2019, this will happen for diabetes and chronic renal failure, only
• This measure will lead to improved outcomes for patients

Measure 4 - Make funding for psychiatric facilities more equitable

• Great inequalities exist in the funding of this sector. The funds will be allocated inter-regionally and intra-regionally in a new manner. Quality indicators will also be introduced, which will influence the financing. Furthermore, some clinics will become a part of the national quantified target (NQT), which will be financed on activity (mostly per hospital day)
• This measure will improve the equity for all the patients throughout the country

Measure 5 - Encourage the emergency services to redirect the lightest patients

• The emergency service should only cope with the most severe cases
• A special ‘coordination package’ will be designed, which will be paid to the emergency service for the patients who would be directed to an outpatient care center, or who just had a consultation
• Patients will become better oriented and the waiting time at the emergency department will be reduced

Domain 2 – Outpatient care: strengthening primary care

Measure 6 - Strengthening primary care

• The objective is to improve the quality of primary care
• This measure aims to group the physician with a nurse, which could have several roles: support chronic patients, taking basic information from patients
• This measure will provide multiple benefits: it will save GP’s time and the patients will have someone more accessible to reach out to. Thus the patients will become more oriented towards outpatient care, which will lead to better prevention (fewer complications and less hospitalization)

Domain 3 – Measure 7 – Improve the fairness and credibility of ONDAM regulation

• Regulatory mechanisms should be revised accordingly to ensure accountability of the actors and the
  credibility of regulation
• The objective of the measure is to reinforce the sub-annual regulatory tools with alert mechanisms that can also be triggered by sub-objectives of the national health insurance expenditure target (ONDAM). Another objective is to introduce a multi-year plan that encourages the rigorous management of ONDAM by allowing future re-use of possible sub-executions, but also the development of moderation and relevance agreements which would allow better regulation of the expenses in the long run
• This measure would increase the efficiency of the healthcare system

See the full report in French here.

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