Changes to health service planning, purchasing and delivery

Prices and delivery of medical goods

Under the 2013 Social Security Financing Law, lower prices for drugs and medical devices in both the ambulatory and hospital sectors are expected to result in savings of €1 billion, after price reductions have been repeatedly practised in previous years. This has been accompanied by incentives to control costs on the delivery side: in 2011, pharmacist remuneration was made partly independent of sales volume to encourage the dispensing of cheaper drug alternatives, which was complemented in 2012 by a pay-for-performance component rewarding the delivery of generic drugs (Caisse nationale de l'assurance maladie des travailleurs salariés, 2013).

Health workforce and salaries

The crisis had a varied effect on the income of the physician workforce, depending on the workplace setting, but there was no specific policy to cut remuneration.⁶ While GPs in private practice saw their incomes decrease for two consecutive years from 2008 (a decrease of 0.66% and 1.73% in 2009 and 2010, respectively), specialists in private practice experienced an increase of 3.18% between 2009 and 2010, after a decrease in the previous year (Caisses Autonome de Retraite des Médecines de France, 2012). Salaries of physicians in public hospitals (who have the status of civil servants) decreased by 0.6%

between 2009 and 2010, representing a more significant decrease than the 0.2%

experienced by civil servants in regional and local administration in the same period. The crisis, however, does not appear to have significantly affected the physician workforce: the growth rate of the number of practising doctors has been constantly decreasing for decades, going from 1.4% in 2002–2003 down to 0.5% in 2007–2008 and nearing zero between 2010 and 2013 (Conseil National de l'Ordre des Médecins, 2013). In public hospitals, the number of doctors increased by 1.6% between 2008 and 2009, by 1.8% between 2009 and 2010, and by 0.3% between 2010 and 2011 (DREES, 2011, 2012c, 2013).

Payment to providers

Pay for performance for GPs was introduced on a voluntary basis in 2009 and generalized and expanded as part of the 2012 agreement between SHI and GPs, with GPs receiving, on average, an additional 5% of their regular income. The pay-for-performance scheme encourages GPs to develop prevention activities, improve treatment and follow patients with a range of chronic conditions (mainly hypertension and diabetes), and to improve efficiency by increasing the rate of generic prescribing. The objectives are based on public health priorities set by parliament and recommendations issued by the French National Agency for Medicines and Health Products Safety (Agence nationale de sécurité du médicament et des produits de santé)⁷ and the National Health Authority (Haute Autorité de santé).⁸ An internal evaluation (with a control group) by SHI suggests moderate improvements, for example in the prescription of testing for glucose control (glycated haemoglobin, HbA1c) for diabetic patients and of low-dose aspirin for patients with heart failure. In 2012, pay for performance was also included in the SHI agreement with cardiologists.

6 All figures concerning physician income in this section account for inflation.

7 The National Agency is the competent authority for all safety decisions concerning health products from their manufacturing to their marketing. It carries out three core missions: (1) scientific evaluation, (2) laboratory and advertising regulation, and (3) inspection of industrial sites. It also coordinates vigilance activities relating to all relevant products.

8 The National Health Authority was set up in 2004 to bring together under a single roof a number of activities designed to improve the quality of patient care and to guarantee equity within the health care system. Its activities range from the assessment of drugs, medical devices and procedures to the publication of guidelines and accreditation of health care organizations and certification of doctors (Chevreul et al., 2010).

FFS payment levels for certain health professionals, such as radiologists and pathologists, were decreased in 2011, and official tariffs for laboratory and other diagnostic tests and services were reduced throughout 2011, 2012 and 2013.

Along with the reduction of drug prices, these measures have formed key elements in the effort to slow health expenditure and limit the health budget deficit.

Overhead costs: restructuring the Ministry of Health and purchasing agencies

In 2009, the Health Reform Act created the National Agency to Support the Performance of Health and Social Care Organizations and Services (Agence nationale d'appui à la performance des établissements de santé et médico-sociaux), with the mission of helping all health care facilities (both private and public) and social care providers to modernize their management, optimize their real estate assets and monitor and improve their performance to control spending. In addition, a reform to support the pooled procurement of hospital supplies was introduced in 2011, with the aim of achieving lower prices. Finally, since 2008, a series of measures have been undertaken by SHI to address fraud.

Provider infrastructure and capital investment

Financed largely through borrowing, €10  billion was allocated to a five-year hospital sector investment plan from 2008 to 2012, called Hôpital 2012. In light of the increasing debt levels of public hospitals (Fig. 3.4),⁹ the aim was to maintain the previous level of hospital investment to support regional planning goals, the development of HTA systems and the updating of safety standards.

The first portion of €2.2 billion was spent in the first three years. In 2013, an expenditure of €354 million on capital investments in the hospital sector was planned, with a third of the funds dedicated to improving information systems to improve efficiency. Concomitantly, in 2013, the European Investment Bank signed an agreement to invest €1.5 billion in the hospital sector over three years.

Priority setting or protocols to change access, coordination of care and patterns of use

The 2013 Social Security Financing Law sought to achieve efficiency savings by shifting care from hospitals to primary and community care settings. In this context, incentives were put in place to encourage day surgery and hospitalization at home. Economic evaluations as part of the HTA process became mandatory, starting in October 2013. In addition, the long-term care programme introduced in 2012 provided care pathways for certain chronic diseases (including chronic obstructive pulmonary disease, Parkinson's disease, chronic kidney failure and

9 In France, public hospitals account for three-quarters of acute medical care capacity (80% of medical beds and 70% of day-care beds) and perform 75% of full-time episodes and 55% of day-care episodes.

chronic heart failure) and working documents on the improvement of care organization for older people in 2013. DMPs have also been implemented. A voluntary DMP for diabetic patients was introduced in 2008 as a pilot project and by 2013 had 500 000 participants. A similar programme has been developed for patients with asthma. Finally, new case management programmes seek to facilitate home care after hospital discharge for childbirth or heart failure.