SURVEY – The third-party payment includes more complementary services in the coverage of care. With attractive offers, for some; the upcoming introduction of a bonus-malus system, denounce the others. Faced with the need for financing, the experts recommend defining a “solidarity” health basket. Countries are thinking about radical solutions.
It has been almost fifteen years since the health insurance accounts have been balanced. In 2014, its deficit stood at 6.5 billion euros. And each time the governments of the right as of the left try to plug a gaping hole with plaster. The successive savings plans are not up to the real challenges. Life expectancy is increasing and older and older people are suffering from serious and costly illnesses. The bill for treatments to take care of them is skyrocketing. For example, that of new chemotherapies for cancer (by infusion or by tablets) weighs more than a billion euros per year.
So, to avoid the cessation of repayment or not to leave an abysmal debt to future generations, health experts are calling for a radical change. At the risk of seeing our model based on solidarity explode. A new French model will therefore have to emerge in which complementary health insurance (mutuals, insurers) intend to play a leading role. They are also engaged in a real battle to attract customers. Today with bonuses, but what will be the rewards tomorrow? Will we see our health coverage rate adjusted according to our behavior? Will you have to stop smoking or eat five fruits and vegetables a day to avoid penalties? Clearly, as with our car, are we going to become drivers responsible for our health. Why actor wanted to know more.
The disaster scenario
Dr Jean-Paul Ortiz is hardly optimistic. The president of the main union of liberal doctors, the CSMF (1), believes that giving more space to complementary health would be a disaster. For him, the new generalized third-party payment system that mutuals want to manage is a warning sign.
“We are in the process of changing the health financing system in this country. We can clearly see that Social Security (which is based exclusively on solidarity) is gradually withdrawing, in favor of complementary insurers whose base is to free up margins, including for the benefit of the stock market. “
With this advance fee waiver, doctors will lose their independence. And enter into care channels. Thus, insurers could, according to him, in the long term, influence prescribers to make them less spendthrift, “outside of any public health interest”.
These channels for the moment only exist in optics and dentistry and allow patients who integrate them (via a supplement) to have a better reimbursement rate on a pair of glasses for example.
And Dr Ortiz goes even further: “Complementaries will set up a modulation of reimbursements according to patient behavior. By interfering in their lifestyle (alcohol, tobacco …). ”
Users for the principle of responsibility
On paper, the French are not opposed to it. A recent study by Deloitte reveals, for the first time, that 70% of them are in favor of adjusting reimbursements according to risky behavior (alcohol, tobacco, etc.). A position that makes you leap Christian Saout, Deputy Secretary General of the CISS, the collective representing patient associations. “Penalizing the patient according to his behavior, he believes, has no use in terms of public health and that is not how we treat patients. Behavior-based reimbursement was tried in the United States (utilitarian thinking) a decade ago, but private insurers have abandoned it. And according to him, in France, we would do well to take the same route.
Christian Saout, Deputy Secretary General of the CISS: “ Let’s get started. Let’s put a connected scale in the homes of diabetic patients. And tell them that we will no longer reimburse (…) We will laugh… “
In fact, this debate only seems topical across the Channel. The English are in fact currently having important thoughts on this subject. In the last election in the country, a GCC (regional committee) in Devon, southern England attempted, unsuccessfully, to set up an experimental plan to close its £ 14.5million deficit, by limiting access to certain care for smokers and obese people.
Not effective according to economists
Same story for Brigitte Dormont, member of the Economic Analysis Council, body which advises Matignon. This professor of economics at Paris Dauphine does not see this scenario emerging in France either. She emphasizes, that in addition, the Evin law of 1989 prohibits insurers from individually increasing the premium of an individual whose state of health deteriorates. There is also a tax bonus for complementary products that do not select the risks with a subscription questionnaire. Finally, this option has not been considered for a long time by insurers, because it is not economically profitable.
But she explains that yet, in practice, risk selection can be practiced indirectly, by adjusting contracts to target particular audiences. “There may be competition on the scope of the contract which allows risks to be selected. I will give you a very simple example: mutuals make a contract that does not cover glasses beyond the negligible tariffs retained by Social Security and there they will not have anyone over 40 years old. ”
This system allows them, it is true, to have contracts very adjusted to attract only a targeted audience. Thus, in one type of contract, all the young people will be together, and in the other, all the elderly. “This technique results in the elderly in poor health ending up with huge bonuses which sometimes represent 10% of their income,” she concludes.
Brigitte Dormont, member of the Economic Analysis Council: “ Colleagues did a study on social inequalities in health (…) They wanted to see if for some people were responsible because they drank or smoked. In all cases, the effort only plays a role for 8%… “
Insurers rely on bonuses
For their part, insurers are sweeping away this strategy of modulating reimbursements according to behavior. “We’re not denying that we’re interested in behavior. The proof is that nicotine substitutes are already being reimbursed. But penalties for those who are not virtuous, it is not on the agenda ”, warns the Dr Philippe Presles, Health Research & Development Director for AXA France.
This tobacco specialist recalls in passing that the public authorities are also “totally opposed”. At present, its complementary, like the others, wants to be rather attractive with its customers. And in this battle, AXA insurance has already made good progress and will, for example, be offering a medical teleconsultation offer from June.
For 50 euro cents per year, the 2.2 million members of the group’s health contracts will benefit from this service available 24 hours a day, 7 days a week. The service offered extends from diagnosis to additional examinations, via the prescription transmitted to the attending physician and to the pharmacy.
To doctors worried by the device, Dr. Philippe Presles maintains that it is a “service approach” which could well arrange them by unblocking, why not, their practices. But the group does not intend to stop there and is already preparing free health applications (Smilesrun for beginner runners) while taking an interest in connected objects.
Philippe Presles, Health Research & Development Director for AXA France: “ We will be experimenting with our customers with a new, more comfortable self-measuring device for blood glucose. People no longer need to prick themselves with it. They only place a sensor for 15 days on the skin… “
But no question for this doctor to make gadgets or the cops. The company he represents, Axa, would only play a role of assistance in health, as for travel or the automobile …
Words that Professor André Grimaldi, one of the founders of the Movement for the Defense of Public Hospitals (MDHP), does not believe. Opposed to the ever increasing weight of complementary, he stresses that policyholders will pay these bonuses. “These are baits, to organize the health system and make it business. Insurance premiums have increased 5-7% per year for 10 years. People are fed up with paying twice. For the Social Security which reimburses poorly the current care and for their insurance which costs more and more expensive. “
Prof. André Grimaldi, one of the founders of the MDHP: “ The total health budget is 240 billion. Private insurers think it’s not possible for it to continue like this. They want to put money in there on condition that they organize the health care system themselves by creating care networks. “
The proposal of the “solidarity” care basket
Faced with this situation, all the players in the world of health seem to agree on a basket of “solidarity” care to be redefined, with everything that the Health Insurance would reimburse at 100% on the one hand, and the rest for the complementary ones. “Today, it seems inevitable,” concludes Professor André Grimaldi.
(1) Confederation of French Medical Syndicates
Read the rest of our survey:
Reimbursement of care: experts call for a solidarity health basket
Reimbursement of care: the NHS hunts down smokers and obese people
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