The evolution of healthcare funding in France

29

Oct 2018

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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08

Sep 2017

All significant innovations in Norway should undergo either national or hospital-based health technology assessment within “New Methods” framework. Guiding criteria for prioritization of topics for assessments were recently formulated by the administration of the program.

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06

Sep 2017

French National Authority for Health (HAS) released new decisions about add-on and medical aid reimbursement of medical devices from the meetings of the National Commission for Evaluation of Medical Devices and Health Technologies (CNEDiMTS) in August 2017. They include different types of stents and stent-grafts for multiple indications (coronary, peripheral vascular), mechanical thrombectomy devices for stroke, medical devices applied for treatment of ulcer of venous origin, remote monitoring for Implantable Cardioverter Defibrillator Systems (ICDS).

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04

Sep 2017

There is an ongoing process to change the structure of add-on reimbursement for peripheral vascular stents in France. In July 2017 CNEDiMTS issued additional clarifications about proposed reimbursement requirements for stents and stent-grafts. Read about proposed changes in our post.

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30

Aug 2017

There is an ongoing process to establish add-on reimbursement for FFR guidewires. Earlier in 2017 two guidewires (Verrata & Verrata More, Philips Volcano; Pressurewire (Certus - Aeris – X), Abbott) received a positive assessment by the National Commission for Evaluation of Medical Devices and Health Technologies (CNEDiMTS) with moderate improvement vs. standard of care. In June 2017, COMET device also received a positive recommendation from CNEDiMTS (no improvement vs. already recommended devices) only on the basis of data about technical equivalency. This is unusual for brand-specific applications and may be an interesting precedent for further applications.

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10

Aug 2017

The National Commission for Evaluation of Medical Devices and Health Technologies (CNEDiMTS) reviewed indications for number of devices on the LPPR list and made recommendations about structure of the section in the LPPR list.

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07

Aug 2017

French National Authority for Health (HAS) released new decisions about add-on and medical aid reimbursement of 10 medical devices from the meetings of the National Commission for Evaluation of Medical Devices and Health Technologies (CNEDiMTS). They include microprocessor controlled knee prosthesis, transcatheter pulmonary valve, deep brain stimulation device, kit for self-monitoring of blood glucose and others.

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24

Jul 2017

HAS is the key decision-making body in relation to evaluation of sufficiency of clinical evidence to establish add-on reimbursement for medical devices, development of new procedure (CCAM) and clinical biology (NABM) codes in France. Annual report provides valuable insights into evaluation landscape for medical device and IVD tests. MTRC has extracted key facts related to assessment of medical technologies from the report.

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19

Jul 2017

Researchers evaluated care process, access, administrative efficiency, equity and health care outcomes in 11 countries on the basis of published health care statistics for 72 indicators. The best overall performers among European countries were the UK (ranked 1st), the Netherlands (3rd), Norway (4th), Sweden and Switzerland (6th). Germany (8th) and France (10th) were low in the ranking.

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11

Jul 2017

Recently, CNEDiMTS at HAS issued positive recommendation for inclusion of HeartMate 3 ventricular assist device into add-on reimbursement catalogue (LPPR title III). No added value was established vs earlier version of device (HeartMate II), despite better safety profile demonstrated in the randomized controlled trial.

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03

Jul 2017

French National Authority for Health (HAS) released new decisions about add-on and medical aid reimbursement of 8 medical devices from the meetings of the National Commission for Evaluation of Medical Devices and Health Technologies (CNEDiMTS). They include coronary stents, portable oxygen concentrators, Urolift device, spinal ganglion stimulator and insulin pumps.

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23

Jun 2017

An assessment was initiated earlier this year on the request from Dutch Hypertension Society and umbrella organization of 9 health insurance companies Zorgverzekeraars Nederland. The Institute will evaluate compliance of baroreflex activation therapy (BAT) for treatment of resistant hypertension with the state of science and practice.

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20

Jun 2017

In May 2017, CNEDiMTS at the National Authority for Health (HAS) issued positive assessment of Urolift for add-on reimbursement via LPPR list. Added value was found to be minor in comparison with transurethral resection of prostate (TURP). This assessment provides better results compared to the earlier one in January 2017. Add-on reimbursement might be established within about one year period.

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08

Jun 2017

Administrators of the “New Method” program, which is focused on managed introduction of innovations into Norwegian system, have initiated technology assessments of 10 technologies and now have requested manufacturers to make submission of clinical and economic evidence.

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06

Jun 2017

HAS published updated program that defines priority areas of work for 2017, including evidence review as part of developing new procedure codes for robotic surgery, endoscopic procedures, and technology assessments of remote monitoring, dialysis, coronary stents and others.

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31

May 2017

French National Authority for Health (HAS) released new decisions about add-on and medical aid reimbursement of 9 medical devices from the meetings of the National Commission for Evaluation of Medical Devices and Health Technologies (CNEDiMTS) in May and April. Among others decision included MRI compatible and recharge free spinal cord stimulation devices, resorbable plates for osteosynthesis.

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17

May 2017

At the meeting of 18th of April National Commission for Evaluation of Medical Devices and Health Technologies made decisions about add-on reimbursement of 17 medical devices. Ten decisions have been released to date for orthopedic, osteointegrated processing, cardiac and intravascular devices.

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16

May 2017

Cédric Carbonneil from the Ministry of Health published a letter in Value in Health in response to the article "New French Coverage with Evidence Development for Innovative Medical Devices: Improvements and Unresolved Issues" published in January 2016. Dr Carbonneil offers an interesting insights into background, rationale and direction of development of this important coverage with evidence development program for medical devices, in-vitro diagnostics and medical procedures in France.

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10

May 2017

This post presents an extract from our reimbursement analysis for angioplasty of arteries of lower extremities with stenting using bare metal and drug-eluting stents for peripheral arterial disease in England, France and Germany. Procedure is reimbursed via combination of diagnosis-related group (DRG) and add-on reimbursement in England and France and solely via DRG in Germany.

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09

May 2017

National Commission for the Evaluation of Medical Devices and Health Technologies (CNEDiMTS) positively appraised Verrata and Verrate Plus guidewires for add-on reimbursement via LPPR title V. Level of added clinical value was considered moderate (ASA III) in comparison with management strategy, based solely on angiography data. This decision complements decision early this year in relation to St. Jude Medical’s (now Abbott) PressureWire FFR wires.

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08

May 2017

Ministerial decree to enlist Medtronic's IN.PACT Admiral for the LPPR title V for add-on reimbursement was published on 6th of May 2017 in the Official Journal of French Republic. This is not only the first peripheral DCB on the List, but one of the first invasive non-implantable devices to get add-on reimbursement in France.

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08

May 2017

French National Authority for Health (HAS) has initiated an assessment of organizational impact of mechanical thrombectomy on the system of stroke management in France with objective to find the most adequate way of further introduction of the method into French health care system.

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05

May 2017

A new decree changed reimbursement approach for critical care in France. Before, it was reimbursed via daily supplements on top of base DRG tariff. New model introduces a mixed payment system with daily supplements and additional annual flat-rate fee, which depends on the size of the intensive care unit and activity in the previous year.

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04

May 2017

Check out reimbursement summary for the most established transcatheter mitral valve repair procedure in England, France and Germany. Reimbursement is established in Germany and France (for one indication). It is in process to be established in England and in France (for other indications).

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02

May 2017

The Forum of Norwegian payers made decision about introduction of three medical technologies: mechanical thrombectomy for stroke, baroreflex activation therapy for resistant hypertension and non-invasive prenatal testing for detection of trisomy 13, 18 and 21.

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01

May 2017

This post presents an extract from our reimbursement analysis for angioplasty of arteries lower extremities using plain and drug-coated balloons (DCBs) for peripheral artery disease in England, France and Germany. Plain balloon angioplasty is reimbursement via DRG solely and DCBs are reimbursement via combination of DRG and add-on reimbursement.

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19

Apr 2017

The French National Authority for Health (HAS) has released report about evaluation of cardiac defibrillation probes and proposed updated nomenclature.

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