Private healthcare - France

[I am Groot]

I have been aware that France has always been among the top performers in the world for healthcare. I wasn't aware until reading this article that almost all of their system is privately funded and privately delivered. The really interesting part is it's comparing the troubled British NHS system, which is mostly government-funded, with the French system, and that both cost roughly the same yet have wildly different performances.

This supports the belief of many, like myself, that the real problem of Canada's healthcare system isn't what is being spent but its organization, the labyrinth of bureaucracy and administration that siphons off so much money from actual healthcare. Not to mention that all decisions, such as whether to build a hospital or how many doctors and nurses to train, are in the hands of the government.

Nothing akin to the NHS exists in France. In a country where the state is normally supreme, medical care is almost entirely delivered privately. There are no diversity, equity and inclusion officers. There are no trans flags painted on the sides of hospitals. No bed blockers. No vast legions of administrators counting paper clips.

GP surgeries answer the telephone almost immediately. You can get an appointment within a day or two, or immediately if it’s urgent.

 

https://www.spectator.co.uk/article/french-healthcare-makes-the-nhs-look-like-bedlam/

[CdnFox]

5 minutes ago, I am Groot said:

This supports the belief of many, like myself, that the real problem of Canada's healthcare system isn't what is being spent but its organization,

That is quite true, although it's deeper than just 'beurocracy'.  Gov's are slow reacting to market needs. Gov'ts take forever to do or build anything. gov'rs are afraid to spend money because it's always criticized.  Gov's always have to make sure the unions are happy and so on and so forth.

Private enterprise is much faster and more effective.

[SpankyMcFarland]

My impression is that UK healthcare spending is considerably lower than that of France by most measures:

https://www.health.org.uk/news-and-comment/charts-and-infographics/how-does-uk-health-spending-compare-across-europe-over-the-past-decade

That Spectator article quoted in the OP is heavy on anecdotes but does concede that the French system is ‘slightly’ more expensive. Like Canada, both systems aim to provide universal health care - ultimately, the government is the main payer. However, mandatory personal health insurance seems to be a feature of many successful systems, e.g. Germany, France, the Netherlands, and it’s something we should consider here. (BTW I’m not sure our doctors would like the incomes of their French counterparts. Another day’s work.) In fairness, all these countries have advantages of population density over us. I think our best peer is Australia - similarly vast and sparsely inhabited with a federal system, high standard of living and an indigenous population. On many measures, the land down under is moving ahead of us. 

Edited September 10 by SpankyMcFarland

[Michael Hardner]

8 minutes ago, SpankyMcFarland said:

My impression is that UK healthcare spending is considerably lower than that of France by most measures:

https://www.health.org.uk/news-and-comment/charts-and-infographics/how-does-uk-health-spending-compare-across-europe-over-the-past-decade

 

Here are the 2022 numbers

 

France just ahead of Canada, UK significantly lower.

https://en.m.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita

 

[I am Groot]

6 hours ago, Michael Hardner said:

Here are the 2022 numbers

 

France just ahead of Canada, UK significantly lower.

https://en.m.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita

 

Even with this all it shows is money is not the cause. Because Canada is significantly lower than France in pretty much every metric. I'm in the nation's capital and here you're not even assured of an ambulance if you have a heart attack or stroke. Every day, sometimes multiple times a day, there are zero ambulances available to respond to emergencies here.

6 hours ago, SpankyMcFarland said:

My impression is that UK healthcare spending is considerably lower than that of France by most measures:

https://www.health.org.uk/news-and-comment/charts-and-infographics/how-does-uk-health-spending-compare-across-europe-over-the-past-decade

That Spectator article quoted in the OP is heavy on anecdotes but does concede that the French system is ‘slightly’ more expensive. Like Canada, both systems aim to provide universal health care - ultimately, the government is the main payer. However, mandatory personal health insurance seems to be a feature of many successful systems, e.g. Germany, France, the Netherlands, and it’s something we should consider here. (BTW I’m not sure our doctors would like the incomes of their French counterparts. Another day’s work.) In fairness, all these countries have advantages of population density over us. I think our best peer is Australia - similarly vast and sparsely inhabited with a federal system, high standard of living and an indigenous population. On many measures, the land down under is moving ahead of us. 

I don't have a monkey in the show in terms of what type of system is used. Whether it's 100% public, 100% private, a mixture, or something done through insurance like the countries you name. I just want the one that will work. And ours clearly doesn't. Yet anytime anyone suggests any significant change you can hear the shrill cries of "American style!" echoing through the streets.

Edited September 10 by I am Groot

[August1991]

In Quebec, I can choose between private and public healthcare.

You don't do this elsewhere in Canada?

https://en.wikipedia.org/wiki/Chaoulli_v_Quebec_(AG)

====

I was recently in Ontario and I asked a (wealthy, older, born 1950) woman about her cataract surgery. Private or public, I asked.

She was perplexed. Public, she said.

I did not ask whether the new lens was an IOL. She merely pointed to her left-eye. Her right-eye was due in a few months. 

 

Edited September 11 by August1991

[BeaverFever]

20 hours ago, I am Groot said:

I have been aware that France has always been among the top performers in the world for healthcare. I wasn't aware until reading this article that almost all of their system is privately funded and privately delivered. The really interesting part is it's comparing the troubled British NHS system, which is mostly government-funded, with the French system, and that both cost roughly the same yet have wildly different performances.

This supports the belief of many, like myself, that the real problem of Canada's healthcare system isn't what is being spent but its organization, the labyrinth of bureaucracy and administration that siphons off so much money from actual healthcare. Not to mention that all decisions, such as whether to build a hospital or how many doctors and nurses to train, are in the hands of the government.

Nothing akin to the NHS exists in France. In a country where the state is normally supreme, medical care is almost entirely delivered privately. There are no diversity, equity and inclusion officers. There are no trans flags painted on the sides of hospitals. No bed blockers. No vast legions of administrators counting paper clips.

GP surgeries answer the telephone almost immediately. You can get an appointment within a day or two, or immediately if it’s urgent.

 

https://www.spectator.co.uk/article/french-healthcare-makes-the-nhs-look-like-bedlam/

The info in your OP is misleading. France has a universal public system. On the service delivery side not unlike Canadas where service is mostly privately delivered but publicly managed (although significant differences including more government control in some areas such as setting quotas and limits on the number of medical students while also having less government control in other ares). On the insurance/ coverage side there is universal public coverage which in many cases doesn’t cover 100% of the cost therefore is supplemented by private coverage which is primarily obtained through employers. . Up until the year 2000 it appears to have been more like an Obamacare type insurance system (ie coverage was primarily through mandatory private workplace coverage with state-funded coverage only for specific groups such as retirees) but since then it has been universal government-provided coverage. The funding model appears to be more like what we have for CPP and EI, which is to say fixed payroll contributions and a dedicated investment fund   In Canada the healthcare budget is simply taken from general revenue each year and not from a dedicated and separate fund  :

 

 

The French government sets the national health strategy and allocates budgeted expenditures to regional health agencies, which are responsible for planning and service delivery. Enrollment in France’s statutory health insurance system is mandatory. The system covers most costs for hospital, physician, and long-term care, as well as prescription drugs; patients are responsible for coinsurance, copayments, and balance bills for physician charges that exceed covered fees. The insurance system is funded primarily by payroll taxes (paid by employers and employees), a national income tax, and tax levies on certain industries and products. Ninety-five percent of citizens have supplemental insurance to help with these out-of-pocket costs, as well as dental, hearing, and vision care.

How does universal health coverage work?

Universal coverage was achieved over seven decades by extending statutory health insurance (SHI) to all employees (in 1945), retirees (in 1945), the self-employed (in 1966), and the unemployed (in 2000). In 2000, the Couverture maladie universelle(Universal Health Coverage), or CMU, was created for residents not eligible for SHI, although the program required yearly renewals and entitlement changes whenever a beneficiary’s professional or family situation changed. After the implementation of CMU, fewer than 1 percent of residents were left without baseline coverage.

In January 2016, SHI eligibility was universally granted under the Protection universelle maladie (Universal Health Protection law), or PUMa, to fill in the few remaining coverage gaps. The law also replaced and simplified the existing system by providing systematic coverage to all French residents. It merged coverage for persons previously covered by the Universal Health Coverage and immigrants covered by the state-sponsored health insurance.¹

Role of government: The provision of health care in France is a national responsibility. The Ministry of Social Affairs, Health, and Women’s Rights is responsible for defining the national health strategy. It sets and implements government policy for public health as well as the organization and financing of the health care system.

Over the past two decades, the state has been increasingly involved in controlling health expenditures funded by SHI.² It regulates roughly 75 percent of health care expenditures on the basis of the overall framework established by Parliament. The central government allocates budgeted expenditures among different sectors (hospitals, ambulatory care, mental health, and services for disabled residents) and regions.

The Ministry of Social Affairs, Health, and Women’s Rights is represented in the regions by the Regional Health Agencies, which are responsible for coordinating population health and health care, including prevention and care delivery, public health, and social care.

Role of public health insurance: Total health expenditures constituted 11.5 percent of GDP in 2017, which amounted to EUR 266 billion (USD 337 billion); 77 percent of those expenditures were publicly financed.^3,4

SHI financing is supplied as follows^5,6:

• Payroll taxes provide 53 percent of funding, with employers paying 80 percent of the tax and employees paying the rest; contributions are calculated from the actual salaries, capped at EUR 3,311 (USD 4,191) per month.
• A national earmarked income tax contributes 34 percent of funding.
• Taxes levied on tobacco and alcohol, the pharmaceutical industry, and voluntary health insurance (VHI) companies provide 12 percent of funding.
• State subsidies account for 1 percent of funding.

Coverage is compulsory, and is provided to all residents by noncompetitive statutory health insurance funds; historically, there have been 42 funds. Annual contributions are determined by Parliament. The SHI scheme in which workers enroll is based upon the type of employment. Unemployed persons are covered for one year after job termination by the SHI scheme of their employer and then by the universal health coverage law. Citizens can opt out of SHI only in rare cases, such as when they are employed by foreign companies.

The state finances health services for undocumented immigrants who have applied for residence. Visitors from elsewhere in the European Union (EU) are covered by an EU insurance card. Non-EU visitors are covered for emergency care only.

Role of private health insurance: Most voluntary health insurance (VHI) is complementary, covering mainly copayments and balance billing, as well as vision and dental care, which are minimally covered by SHI.

Complementary insurance is provided mainly by not-for-profit, employment-based associations or institutes. Private for-profit companies offer both supplementary and complementary health insurance, but only for a limited list of services. Voluntary health insurance finances 13.5 percent of total health expenditures.⁷ Ninety-five percent of the population is covered by VHI, either through employers or via means-tested vouchers (see more under “Safety nets,” below). As of 2016, all employees benefit from employer-sponsored VHI, for which employees pay at least 50 percent of the cost.

The extent of coverage varies widely, but all VHI contracts cover the difference between the SHI reimbursement rate and the official fee on the national fee schedule. Coverage of balance billing is also commonly offered.

In 2013, standards for employer-sponsored VHI were established by law to reduce inequities stemming from variations in access and quality.

 

How is the delivery system organized and how are providers paid?

Physician education and workforce: Once a year, the Ministry of Social Affairs, Health, and Women’s Rights determines the maximum number of students that can be admitted to medical, dental, midwifery, and pharmacy schools, which are all public by law. Tuition fees are approximately EUR 500 (USD 633) per year.

The number of medical professionals is controlled at the point of entry into medical education. In addition, 12 percent of the current medical workforce are foreign-trained medical professionals. To date, there are no limitations on the number of practicing physicians by region. However, since 2013, outpatient physicians can enter into contractual agreements that guarantee a monthly salary of EUR 6,900 (USD 8,734) if they practice in a region with insufficient physician supply and agree to limit extra billing. For physicians who work full-time in medical centers in underserved areas, the guaranteed salary is approximately EUR 50,000 (USD 63,290) per year.

Primary care: There are roughly 102,299general practitioners (GPs) and 121,272specialists in France (a ratio of 3.4 per 1,000 population). About 59 percent of physicians are self-employed on a full-time or part-time basis (67% of GPs, 51% of specialists).⁹

More than 50 percent of GPs, predominantly younger doctors, are in group practices. An average practice is made up of two-to-three physicians. Seventy-five percent of practices are made up exclusively of physicians; the remaining practices also include nurses and a range of allied health professionals. The average patient panel size is about 900 patients for GPs.

There is a voluntary gatekeeping system for people aged 16 and older, with financial incentives offered to those who opt to register with a GP or specialist. About 95 percent of the population have chosen a GP as their gatekeeper, but specialists can also serve as gatekeepers.

Self-employed GPs are paid mostly on a fee-for-service basis, with fees determined by SHI funds and the Ministry of Social Affairs, Health, and Women’s Rights. In 2018, GP fees were EUR 25 (USD 32) per consultation. GPs can also receive a capitated per-person annual payment of EUR 40 (USD 51) to coordinate care for patients with chronic conditions. In addition, GPs receive an average of EUR 5,000 (USD 6,330) a year for achieving pay-for-performance targets.

In 2014, the average income of primary care doctors was EUR 86,000 (USD 108,860), 94 percent of which came from fees for consultations and the remainder from financial incentives and salary.¹⁰

GPs can bill above the national fee schedule, and 25 percent do. Specialists earn, on average, 1.3 times what GPs earn.

 

https://www.commonwealthfund.org/international-health-policy-center/countries/france#:~:text=Enrollment in France's statutory health,charges that exceed covered fees.

[Michael Hardner]

39 minutes ago, BeaverFever said:

The info in your OP is misleading. France has a universal public system. On the service delivery side not unlike Canadas where service is mostly privately delivered but publicly managed

There is a cultural difference, which needs to be pointed out.  Management is focused on delivery and management, I would say in continental Europe.  Canada's system is top-down, politically driven, and unable to change.

For a person who defends the status quo, I would say this system needs drastic reform.  If we had good management of public resources, perhaps we could trust some privatization to happen without dropping the ball for the public on the whole.

I lived in France and the services were superior, much better than the slightly higher expense indicates.

[SpankyMcFarland]

20 hours ago, I am Groot said:

I don't have a monkey in the show in terms of what type of system is used. Whether it's 100% public, 100% private, a mixture, or something done through insurance like the countries you name. I just want the one that will work. And ours clearly doesn't. Yet anytime anyone suggests any significant change you can hear the shrill cries of "American style!" echoing through the streets.

Who mentioned America here so far? I certainly didn’t. It’s not a ‘model’ worth considering if it can be considered a coherent model at all. Europe, Taiwan, Australasia etc. offer better alternatives that we might learn from. Let’s see if we can agree on some changes to our system. 

Edited September 11 by SpankyMcFarland

[I am Groot]

19 hours ago, August1991 said:

In Quebec, I can choose between private and public healthcare.

You don't do this elsewhere in Canada?

One of the problems Ottawa has with its healthcare is the provincial government allocates resources based on population and doesn't take the population of neighboring west Quebec into account. But healthcare in West Quebec so godawful bad, the delays so long, the ER's so horribly overcrowded that large numbers of Quebecers come to Ottawa to get healthcare.

The reason for that sensible court decision was, of course, that the public version of healthcare could not be relied upon for anything. It's just THAT bad.

Edited September 11 by I am Groot

[I am Groot]

7 hours ago, BeaverFever said:

Physician education and workforce: Once a year, the Ministry of Social Affairs, Health, and Women’s Rights determines the maximum number of students that can be admitted to medical, dental, midwifery, and pharmacy schools, which are all public by law. Tuition fees are approximately EUR 500 (USD 633) per year.

That's a hell of a lot better than here where AFAIK nobody has seriously considered the numbers of students that can be admitted for over 20 years - until last year. The tuition fees for medical education are also absurdly low by our standards, but that could allow for the much lower salaries French doctors get. I mean, as it stands Canadian nurses can apparently make as much as French doctors. I wonder why we don't get more French nurses immigrating to Quebec...

We could do the same for tuition, but we'd need to put in place financial disincentives for doctors, nurses, and others to take the basically almost free training and then skip across the border to practice in the US.

 

7 hours ago, BeaverFever said:

The average patient panel size is about 900 patients for GPs.

That seems kind of odd to me. From what a quick google tells me the Canadian average is only 950 while in Quebec it's 685. Yet family doctors often seem rushed and overworked, without sufficient time to really explore background issues with their patients. Quebecers I know have to wait weeks, sometimes months for appointments with their GP.  I wonder if ours have a lot more paperwork eating up their time. 

7 hours ago, BeaverFever said:

the average income of primary care doctors was EUR 86,000 (USD 108,860), 94 percent of which came from fees for consultations and the remainder from financial incentives and salary.¹⁰

The Canadian comparison is $265k (US$195k) But then, they need to pay off far higher student loans. And we need to compete with America or we'll lose them all. Free or nearly free tuition combined with a requirement they pay off the real cost if they leave (the real cost being the cost if not subsidized AT ALL by the government, more like what a foreign student would pay). I wonder if we did away with the requirement to get a bachelor degree before going to medical school, as it is done in a number of other countries would help here. Not only would it reduce the cost and time of training but perhaps it would make them inelliglbe for a quick jump across the border to work in the US.

Edited September 11 by I am Groot

[SpankyMcFarland]

1 hour ago, I am Groot said:

The Canadian comparison is $265k (US$195k) But then, they need to pay off far higher student loans. And we need to compete with America or we'll lose them all. Free or nearly free tuition combined with a requirement they pay off the real cost if they leave (the real cost being the cost if not subsidized AT ALL by the government, more like what a foreign student would pay). I wonder if we did away with the requirement to get a bachelor degree before going to medical school, as it is done in a number of other countries would help here. Not only would it reduce the cost and time of training but perhaps it would make them inelliglbe for a quick jump across the border to work in the US.

How big is net physician migration south? I’ve heard of it but I don’t think it’s on the scale of Irish medical migration to Oz (percentage wise) or the likes of SAfrican/Egyptian//South Asian movement here (in gross numbers).   

As to why French nurses don’t move to Quebec, well, they live in France which is not yet the dystopian nightmare some claim it to be. French people require a big pay differential to give up on their country. 
 

 

Edited September 11 by SpankyMcFarland

[I am Groot]

28 minutes ago, SpankyMcFarland said:

How big is net physician migration south? I’ve heard of it but I don’t think it’s on the scale of Irish medical migration to Oz (percentage wise) or the likes of SAfrican/Egyptian//South Asian movement here (in gross numbers).   

I don't think it is either, but if we lowered their salaries to what doctors are paid in France, which is barely more than half what Canadian GPs are paid, I expect the numbers would increase quite rapidly. And if we didn't, and I assume the salaries of nurses and other healthcare professionals are similarly higher than in France, we would have to put a lot more money into healthcare than France does just to offer up comparable services. 

28 minutes ago, SpankyMcFarland said:

As to why French nurses don’t move to Quebec, well, they live in France which is not yet the dystopian nightmare some claim it to be. French people require a big pay differential to give up on their country. 

You mean their nation. But Canadians are told we have no nation, and are discouraged from having any pride in Canada or its history. And the US isn't across an ocean but just a short drive away.

[SpankyMcFarland]

17 minutes ago, I am Groot said:

You mean their nation. But Canadians are told we have no nation, and are discouraged from having any pride in Canada or its history. And the US isn't across an ocean but just a short drive away.

Also their actual location. France has had a gentler climate than Quebec although their summers are becoming hotter. 

[August1991]

On 9/11/2023 at 11:01 AM, Michael Hardner said:

There is a cultural difference, which needs to be pointed out.  

...

Disagree strongly. There is no cultural difference.

In France, they have two systems. In America, Medicaid and so on...

In Canada (outside Quebec), we have a federal single-payer. 

[Aristides]

1 minute ago, August1991 said:

Disagree strongly. There is no cultural difference.

In France, they have two systems. In America, Medicaid and so on...

In Canada (outside Quebec), we have a federal single-payer. 

Actually, we have provincial single payers.

[August1991]

3 minutes ago, Aristides said:

Actually, we have provincial single payers.

In Quebec, we don't.

Elsewhere in Canada, you think that you do.

======

The more that I have discussed health care on this forum, I have realised that it is an existential issue.

We are not discussing health care.

We are discussing life - and more pointedly, death. 

[Aristides]

1 minute ago, August1991 said:

In Quebec, we don't.

Elsewhere in Canada, you think that you do.

======

The more that I have discussed health care on this forum, I have realised that it is an existential issue.

We are not discussing health care.

We are discussing life - and more pointedly, death. 

No we don't, health care is provincial. The provincial governments get transfers from the feds but the province decides how they are spent.

If we are not discussing health care, why did you name the topic, private healthcare.

[Aristides]

https://www.canada.ca/en/department-finance/programs/federal-transfers.html

[August1991]

1 hour ago, Aristides said:

No we don't, health care is provincial. The provincial governments get transfers from the feds but the province decides how they are spent.

If we are not discussing health care, why did you name the topic, private healthcare.

Our federal Supreme Court has decided that Quebec has a different health care system from the rest of Canada.

True, our provincial governments receive transfer payments.

===

In Quebec, I can go to a private doctor - like in Germsny.

=========

But as I say, any discussion of health care in Canada is a discussion of death/life. We are no longer discussing practical health issues - we are discussing life itself.  

 

Edited September 13 by August1991

[CdnFox]

1 hour ago, Aristides said:

The provincial governments get transfers from the feds but the province decides how they are spent.

No, all expenditures are still subject to the Canadian Health Act, and many provinces have been fined or penalized by the feds for allowing services outside of that.

The provisioning of health care is provincial - BUT subject to the feds requirements,

[August1991]

9 minutes ago, CdnFox said:

No, all expenditures are still subject to the Canadian Health Act, and many provinces have been fined or penalized by the feds for allowing services outside of that.

The provisioning of health care is provincial - BUT subject to the feds requirements,

Not in Quebec.

According to the federal Supreme Court, the federal Canada Health Act does not apply in Quebec.

Edited September 13 by August1991

[Aristides]

22 minutes ago, August1991 said:

Not in Quebec.

According to the federal Supreme Court, the federal Canada Health Act does not apply in Quebec.

Quebec still gets transfers from the feds, same as all the other provinces. Coverage also varies from province to province. I posted the link.

The fact Quebec gets special treatment under the law is a source of friction in this country.

[August1991]

57 minutes ago, Aristides said:

....

The fact Quebec gets special treatment under the law is a source of friction in this country.

Quebec? One could say the same of the Ontario government. The people of Ontario get special treatment.

===

We are a federal State.

Edited September 13 by August1991

[CdnFox]

2 hours ago, August1991 said:

Not in Quebec.

According to the federal Supreme Court, the federal Canada Health Act does not apply in Quebec.

That is not accurate.  where did you see that court ruling.