7.6. Health system efficiency

Health system efficiency concerns maximizing desired outcomes of the health system while optimizing the level of resources devoted to it (Cylus, Papanicolas & Smith, 2016). France has the third lowest treatable mortality rate (i.e. premature deaths that should not occur in the presence of timely and effective health care) per 100 000 population in Europe, closely after Switzerland and Iceland, but Switzerland spends 50% more on health care per capita than France. Although France devotes a high share of its GDP to health care, health expenditure per capita at the international level is lower than in many other European and neighbouring countries. Therefore, as depicted in Fig7.9, the French health system is one of the most efficient in Europe in terms of treatable mortality. For example, Belgium, Germany and the United Kingdom have both higher treatable mortality rates and higher health expenditure per capita.

Fig7.9

Nevertheless, the efficiency of public health interventions focusing on the wider determinants of health such as lifestyle factors is rather low in France, considering the high rates of preventable mortality (Fig7.7). It has been estimated that 48% of deaths before the age of 75 years in men have preventable causes, mainly related to risky behaviours (Insee, 2021c), and about 13% of annual deaths are attributable to tobacco consumption (SPF, 2021a).

Fig7.7

7.6.1. Allocative efficiency

The implementation of macro-level targets, the ONDAM, has been successful in containing overall expenditure in the past decade, reducing the annual growth rate of health expenditure from more than 3% in the mid-2000s to under 2% from 2015 to 2019 (Barroy et al., 2014; OECD, 2021a). However, this strict budgetary process with a segmented approach to health care also became a barrier for improving allocative efficiency (Deroche & Savary, 2019; HCAAM, 2020b). The fact that health care budgets are set and monitored separately for ambulatory care providers, hospitals and LTC facilities creates a form of impermeability between different sectors (see Box3.3) and hinders the potential efficiency gains (for example, through shifting resources from hospital to social care by reducing the number of hospitalizations). This reinforces the division of health care supply at the local level and reduces the capacity to improve care coordination across sectors and to shift care in the community. More importantly, the indicative budgets are set at the national level without reflection on resource allocation across regions, and without considering the health care needs of the population and health priorities at the local level.

Box3.3

Therefore, the current budgeting process has little modified the balance of allocation between different care sectors in the past decade. The system is highly hospital-centric: France has one of the highest hospital discharge rates (184 per 1000 inhabitants in 2019) among the OECD countries (OECD, 2021a), representing almost half of total health spending. Moreover, the lack of coordination between ambulatory, hospital and social (long-term) care providers has been recognized as a major drawback in terms of cost-control and quality and efficiency of care provision. The major reforms aiming to strengthen primary care provision, such as a voluntary gatekeeping scheme and P4P remuneration for ambulatory physicians, do not appear to have had any significant impact on improving care patterns (Naiditch & Dourgnon, 2009; Bras, 2020).

Evaluations showed that compared to traditional (solo) general practice, the implementation of MSPs in France has improved the quality and efficiency of care provision with more emphasis on prevention and care coordination (Mousquès & Daniel, 2015). Therefore, several initiatives and financial incentives have been introduced in the past decade for encouraging such practices. Despite the slow uptake and variations across regions as to the size and distribution of these practices, in 2022 four self-employed GPs out of 10 shared a practice with non-physician health professionals (Bergeat, Vergier & Verger, 2022) vs about a quarter in 2019 (Chaput et al., 2019). More teamwork integrating a diverse mix of professionals may facilitate the innovation of care models to improve service delivery in the future.

France has had success in controlling prices of health care services and pharmaceuticals through formal negotiations with health care providers and value-based pricing of pharmaceuticals. Nevertheless, health care providers tend to compensate for reduced revenues by increasing the volume of services they provide. While health care prices are well below the OECD average (23% less on average), France has the third highest health care volume per capita in OECD countries, 50% above the average (OECD, 2021a). The fact that most health care providers are paid based on volumes (FFS in the ambulatory sector and ABP in the hospital sector) provides an incentive to increase the quantity of care without necessarily improving quality and coordination across settings. Therefore, over the past few years new payment models have been implemented or piloted, including an additional P4P remuneration based on the achievement of public health objectives for self-employed primary care physicians (see section 3.7.2). The SHI also plans to improve the current P4P scheme by introducing new quality indicators based on patient experience, simplifying and extending the P4P scheme to a greater number of medical specialties, and introducing incentives for collaboration between primary and hospital care providers (CNAM, 2022a). The SHI also aims to provide a benchmarking of results among medical professionals to support change in practice, but this may be difficult due to resistance from health professionals.

7.6.2. Technical efficiency

France has significantly improved the technical efficiency in the hospital sector in the past decade (2010–2020), measured using classical indicators such as average length of stay in hospital, day-case surgery rates or hospital volume over hospital resources, and the country performs well internationally (DREES, 2021d; OECD, 2021a). In 2021 a relatively high proportion of surgical procedures, such as eye surgeries (95%), orthopaedic surgeries (53%) and digestive procedures (43%), were performed as day cases rather than inpatient procedures (Scansanté, 2021). While the percentage of ambulatory surgery increased significantly over the past five years, there are significant variations across regions and hospitals. Moreover, over the last decade avoidable hospital admissions, readmissions and visits to EDs have also visibly increased, especially for the older population (Bricard, Or & Penneau, 2020). Financial pressure on hospitals with declining prices over time encouraged hospitals to focus on increasing activity volumes to balance their accounts (see section 3.7.1.3). Indicators such as staff turnover and sickness absence rates, while not available internationally, were already alarming before the Covid-19 pandemic, as, despite the significant increase in case volumes over time, the number of nursing staff in hospitals stagnated and even decreased in some areas. In 2019 professionals working in hospitals were already reporting an excess workload (57% of all hospital professionals vs 40% in other occupational sectors) (Pisarik, 2021). The gap between the workload and demands associated with the work and the means available to do so appeared to fuel frustration amongst 60% of the nurses and nurse assistants, a situation that worsened during the pandemic (Parent, 2022).

Recent policies aiming to reduce avoidable hospitalizations and improve local care coordination include the development of regional/local health care networks (CPTS) which bring together hospital and primary care physicians, nurses and other professionals (including social workers, administrative staff, etc.). Since 2019 new payment models have also been tested on an experimental basis, including bundled payments, which allow for funding to be shared between primary care providers and hospitals. Moreover, GHTs, introduced in 2016, aim to facilitate reorganization of hospital services around the local population by encouraging hospitals to share their resources and activity, and to specialize on certain services. Compulsory for public hospitals, these groups can also include private clinics as partners on a voluntary basis. Finally, a new type of care facility, certified as local hospitals (Hôpitaux de proximité), was introduced in 2015 to enable a stepped-care approach – mostly by following up older patient groups and providing less technical procedures in socially deprived areas where the density of physicians is low and the share of older adults in the local population is high (Milon, 2019). Local hospitals are supposed to serve as a link between primary care providers, higher level hospitals and the social care sector and to facilitate prevention and continuity of care to avoid acute hospitalizations (Order no. 2021-582 of 12 May 2021).

While generic pharmaceuticals have enabled significant cost reductions (an estimated €3 billion in 2018 and more than €27 billion since 2000) (Leem, 2021), their use remains limited in France compared to other European countries. Generics represented only 30% of the market volume of reimbursed pharmaceuticals in 2019 (vs 83% in Germany and 85% in the United Kingdom) (OECD, 2021a). There is also margin for improving prescription patterns as France has high rates of inappropriate prescriptions (OECD, 2020c), and in particular higher rates of antibiotic prescription in primary care which are well above the EU average (23 defined daily doses per 1000 population per day vs 17.4 on average) (OECD, 2021a). In 2022, to reduce waste in pharmaceutical consumption, community pharmacies were given the possibility to dispense a few types of medicines by unit (instead of boxes) (see Box5.7). Moreover, medicines with insufficient or low medical benefits (including homoeopathic medicines since 2021) have been delisted from the benefits basket over time. Efforts to reduce inappropriate prescription (for example, of benzodiazepines for the older population, certain cholesterol medicines and antibiotics) are supported by national education campaigns and a specific P4Q scheme in primary care which has had limited success so far (CNAM, 2022f).

Box5.7

In France all health professionals have legally defined tasks and procedures that they can deliver (Brissy, 2020). This legal approach reduces the technical efficiency of the health system since it gives little possibility for developing competences and task shifting between different providers and for modifying care models to look after an ageing population. Therefore, attempts to promote task transfer from physicians to other professionals, such as nurses, have had limited success, especially as it can also impact the revenues of the professionals involved, who are mainly paid FFS. Therefore, compared to many other European countries, nurses have little medical responsibility and power both in primary care and in hospitals and their competences are underutilized (Or & Gandré, 2021). While an advanced nursing track has recently been created (see section 4.2.2), nurses still have little autonomy in their practice. Given the persistent shortage of GPs in some areas, recent policies also opened the possibility of devolving some medical tasks to other health professionals (such as vaccination for pharmacists, nurses and midwives).

Overall, France lacks a national health system performance assessment (HSPA) framework to monitor and evaluate health systems performance. Major quality indicators across care settings are not systematically monitored and publicly reported. While important progress has been made for collecting data on quality, in particular concerning safety of care in hospitals, most indicators are focused on processes. Major indicators such as 30-day readmission rates, waiting times for treatment and adverse events after surgery are not monitored regularly across providers or across regions/territories. Generally, benchmarking of efficiency and care quality is discouraged even when data are available. This reduces France’s capacity to identify problem areas as well as good practices to push forward policies for improving care quality and efficiency.

Nevertheless, in the frame of the latest national health strategy 2018–2022, a set of outcome indicators was defined for the first time to monitor over time the achievement of objectives set in the strategy (for example, reducing alcohol and tobacco consumption in the adult population, increasing satisfaction with care quality, etc.) (MoH, 2022b). This may constitute a first step for building a performance evaluation system in the long term.