Franchise sur les soins ambulatoires et équité sociale (version anglaise)

Claire Lachaud-Fiume, Christine Largeron-Leténo, Lise Rochaix

Description

L'objectif de maîtrise des dépenses de santé s'est davantage attaché depuis les années 90 à la régulation de l'offre qu'à celle de la demande, en maintenant inchangés le niveau et la structure de la participation financière des usagers. Leur responsabilisation reste cependant au coeur du débat : la mise en place de franchises sur le remboursement des soins pourrait constituer un facteur efficace de réduction du risque moral. Un modèle de microsimulation a été construit pour en évaluer les conséquences à la fois en terme d'équité et du point de vue de leur acceptabilité sociale. Un scénario de référence d'une franchise uniforme pour toutes les familles d'assurés sociaux (FAS), dont le montant serait déterminé par un objectif d'économies globales modéré, conduit pour le seuil de remboursement à un ordre de grandeur de 1 000 F par an et par famille. Par ailleurs, se trouve confirmée l'idée intuitive suivant laquelle un tel dispositif pénalise les familles disposant des revenus les plus modestes. Ce caractère régressif peut être atténué par une fixation individuelle du montant de la franchise, tenant compte de la taille et des ressources de la famille. Une modulation suivant le niveau de revenu par personne, notamment, permet d'aboutir à une situation plus équitable que la situation initiale sans franchise ; le seuil imposé aux familles appartenant à la tranche médiane de revenu s'avère une variable déterminante pour un tel objectif d'équité verticale.

Sujets

• INSEE
• Santé
• Protection sociale

Informations

• Publié par: insee
• Nombre de lectures: 32
• Langue: English

Extrait

An Ambulatory Care
Deductible and Social Equity*
Microsimulation of a User Payment System
for Health Care Services
Claire Lachaud In the 1990s, curbing health care expenditure concentrated more on regulating
Fiume, Christine supply than demand by freezing the level and structure of user cost sharing. Yet
Largeron Leténo making users responsible for their own spending remains a core issue. An effective
and Lise Rochaix- way of reducing the moral hazard could be to introduce a deductible for health
Ranson**
care reimbursements like an excess in insurance policies. A microsimulation model
has been built to evaluate the consequences of this in terms of equity and social
acceptability.
The amount of the deductible would be the same for all covered families and
* Originally published as would be determined by a moderate total savings goal. It would be set at
“Franchise sur les soins
approximately the first 1,000 French francs of health care spending per family perambulatoires et équité
sociale,” Économie et year. Obviously, such a mechanism would penalise the families with the lowest
Statistique, n° 315,
incomes. This regressive aspect could be alleviated by setting individual amounts1998 5.
** Claire Lachaud Fiume by family size and resources. Adjustments, particularly individual income based
works for the Université
Lyon I, URA 934, Chris adjustments, could even produce a more equitable situation than before the
tine Largeron Leténo for introduction of a deductible. Under this hypothesis, the threshold for families in
the Université Jean
Monnet Saint Etienne - the median income bracket is a determinant variable for the vertical equity goal.
LASS Lyon I and Lise
Rochaix Ranson for the
Université de Bretagne
occidentale, Department
of Economy and ICI
ost health systems are based on user particularly good illustration of this. However,Laboratory (Information,
Co ordination and M cost sharing whether in the form of an this has not always been the case. J. P. Rey
Incentives). insurance mechanism as in the United States or (1993) notes that pre 1930 cost sharing was
The authors would like
incorporated into the tax system as in the more like a user charge designed mainly toto thank the Direction
1de la Prévision, the United Kingdom. Yet cost sharing is based on redeem patient registration charges. A long
Direction du Budget two separate types of reasoning. It is either a debate between the French Senate and the
and the Commissariat
sort of user charge that funds part of the totalChamber of Deputies finally led to theGénéral du Plan for
their financial backing spending or an incentive to reduce the moralintroduction of cost sharing proportional to
under a joint research 2hazard. The first is a set, limited sum thatconsumption in 1930. is
agreement and CREDES
the same for everybody. In the second case,and INSEE for providing
data. cost sharing is proportional to consumption. In
The names and dates in France, health system user cost sharing is
1brackets refer to the See Schneider (1998).
basically of the second type: the ticket 2bibliography at the end The moral hazard can be defined as the change in behaviour
of the article. modérateur (patient’s co payment) is a brought about by the presence of insurance.
INSEE Studies no. 38, September 1999 1Box 1
CURBING GROWTH IN HEALTH SPENDING:
TWENTY YEARS OF SAVINGS MEASURES
Many health insurance consolidation plans have - The addition of a 26th affliction to the list of afflictions,
been put forward over the last twenty years. They entitling beneficiaries to 100% reimbursement when
have generally contained proposals to increase the share of the cost they pay exceeds 80 FF/month
revenue and check the growth in expenditure. or 480 FF/month for six months;
- In December 1979, the creation of an extraordinary
The Durafour plan tax on the earnings of pharmaceutical dispensaries.
Presented in December 1975, it included:
- A reduction in VAT on pharmaceuticals (from 20% to The Questiaux plan
7%); Presented in November 1981, it included the
- The removal of the ceiling on the payroll share of introduction of a 1% contribution for the unemployed
health insurance. (above the minimum wage) and the doubling of car
insurance tax paid to the health insurance.
The Barre plan
Presented in September 1976, it included: The Bérégovoy plans
-The exclusion of certain “luxury” drugs from 70% Presented in July and September 1982, they
reimbursement; comprised:
-An increase from 25% to 35% in the patient’s -The freezing of medical fees and pharmaceutical
co payment for medical auxiliary treatment (except product prices and earnings;
nurses); - No increase in the daily allowance rate provided for
- The introduction of a 30% patient’s co payment for after more than three months of treatment;
transport costs; - The creation of the fixed daily hospital fee for hotel
-The introduction of a government contribution to services;
social security funding in the form of a new road tax - The introduction of a total hospital budget, brought
disc. into general use in public hospitals in 1985;
- The reclassification of drugs to treat ailments that are
The Veil plans not normally serious: reimbursement reduced from
The first plan was presented in April 1977 and 70% to 40% for 1,258 drugs;
consisted of: - A 5% tax on pharmaceutical advertising.
-An increase in contribution rates for agricultural
wage earners and workers over 65 years old; The Delors plan
- The introduction of health insurance contributions for Presented in March September 1983, it created a
pensioners; 1% extraordinary levy on taxable incomes, which
-The increase from 30% to 60% of the patient’s was extended to unearned income in September.
co payment for “luxury” drugs; in return, the 90%
reimbursement rate for drugs was raised to 100%. The Dufoix plan
Presented in May June 1985, it comprised an
The second plan was presented in December 1978 increase in the patient’s co payment for certain care
and included: and the reclassification of 379 “luxury” drugs.
-The launch of a health supply control policy to
stabilise and even reduce the number of beds (in bothThe Seguin plan
the public and private sector), control the creation of Presented in November 1986, this plan was
major medical facilities and set an admission quota introduced step by step after a particularly poor year
for second year medical students; in 1986 (a deficit of 7.5 billion French francs for the
-A campaign to prevent social scourges such as CNAMTS). It included:
alcoholism and tobacco addiction; - The extension and revision of the list of 25 afflictions;
- The creation of the Commission des Comptes de la -Exemption from the patient’s co payment limited
Sécurité sociale (social security audit committee). solely to the exempting illness: the beneficiaries
entitled to 100% coverage for a long and costly
The Barrot plan affliction receive this coverage only for the treatment
Presented in July 1979, it consisted of: associated with the exempting affliction (5 May 1987);
-Freezing medical fees until the conclusion of an - Smoothing of the reference period over three months
agreement. This agreement was signed in 1980. In for the calculation of daily benefits;
return for not raising the fees, a new sector (Sector 2)- The end of official paid post;
was created for GPs and specialists wanting to - Actual 40% reimbursement of drugs subject to this
participate in it to freely set their fees. The difference rate (the “40 to 40” measure, 01/01/87). Drugs
between the statutory fee (defined on the basis of a bearing a blue price label are actually reimbursed at
Sector 1 consultation) and the price practised by the the rate of 40% regardless of the beneficiary’s
practitioner formed the balance to be paid by the situation in terms of exemption from the patient’s
patients (or their supplementary insurance where they co payment (formerly, patients exempt from the
have one and where it reimburses the cost); patient’s co payment for reasons of serious affliction
- No daily price increases (for clinics) and compliance were exempt even for blue label drugs used to treat
with initial budgets (public hospitals); ailments that are not normally serious);
2 INSEE Studies no. 38, September 1999Since, other types of cost sharing have of the costs involved. It is only applied to
gradually been introduced alongside the certain services (mainly ambulatory care,
patient’s co payment to satisfy other goals than hospital care paid directly by the insurers and
just the reduction of the moral hazard (see Box drugs sold in certain pharmacies).
1). These are the fixed daily hospital fee, which
separates the hotel part from the health careIn France, user cost sharing is made up of a
part, and balance billing by Sector 2 doctorswide range of methods and forms a
4(GPs and specialists entitled to freely set theinrot inconsiderable share of the total funding
fees) whereby the user pays the difference of health insurance expenditure (CREDES,
between the statutory fee negotiated with the1989). The growing weight of these direct
3 3 This corresponds to producer and the price billed by this producer.
the American conc