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France passes wide-ranging health reforms
World Report
France passes wide-ranging health reforms After some turbulent months of protests by doctors and opposition by MPs, France has a new health law, bringing in a raft of new measures. Barbara Casassus reports from Paris.
Doctors’ dispute Anger over third party payments to be gradually extended to cover all patients by Nov 30, 2017, brought health professionals out on strike sporadically during 2015, but to no avail. The language introducing the measure was even tougher in the final text. Instead of just laying down the principle, and leaving it to practitioners and the administration to work out the details, the measure was made compulsory. Health Minister Marisol Touraine, who kept her job in the Feb 11 government reshuffle despite rumours to the contrary, “had hoped negotiations would be sufficient, but since the doctors’ unions all rejected the www.thelancet.com Vol 387 February 27, 2016
proposal, there was no choice but to impose it by law”, said Tabuteau. But that was not the end of the story. Taking up a complaint from more than 60 opposition parliamentarians from each of the two houses, the Constitutional Council ruled that third party payments for all would apply only to the national health and not to top-up private insurance. The text guaranteed doctors would be reimbursed within 7 days, but it said nothing about how President François Hollande’s promised “simple” mechanism for payment from France’s more than 500 health insurers would work.
population of 65 million who suffer long-term illness or undergo costly treatment and are taken fully in charge, he predicted. Overall, Tabuteau gives the law seven out of ten for what it includes, but much less for what it leaves out. “Nothing has been done to change the dual structure, whereby public hospitals report to the state and community practitioners report to the health insurance administration”, he said. “Nothing has been done either to iron out the huge inequalities in complementary health insurance”, he added.
“‘It might not be the deepest health reform since World War 2, but it is certainly the widest...’”
Positive steps
Touraine had hoped that the top-up payments issue would be remedied by the announcement of a streamlined system, that patients would demand third party payments for extra fees, and that doctors would offer it when they saw how straightforward the reimbursement process would be. And with presidential elections in 2017, note the cynics, Touraine would not risk upsetting health professionals again with a fresh attempt to push through unpopular legislation. But the unveiling of a dual public– private system to the profession on Feb 17 did nothing to quell doctors’ ire. Claude Leicher, president of MG France, the leading general practitioners union, said: “We are not against the principle of third party payments, but we need a one-stop shop for billing and reimbursements. Otherwise we would spend far too much time on paperwork.” The result of the dual system is that third party payments will be provided only to the 11 million patients out of the
By contrast, important steps have been taken to strengthen individual and patient association rights, said Anne Laude, director of the Graduate School of Law at the Paris-Descartes University, and co-director of the university’s Health and Law Institute. For the first time in France, people with cancer and other illnesses will have the “right to be forgotten” when seeking a bank loan or buying health insurance after 10 years in remission for adults and 5 years if the disease is diagnosed before the patient turns 18 years. The
Damien Meyer
France’s most voluminous health bill in living memory has finally become law, despite furious protests from the medical profession over plans to introduce third party payments for all, and a rap on the government’s knuckles in the final stages. The bill started out with just 57 articles, but after a 15-month passage through parliament ended up with 227 after both houses had adapted, amended, or augmented just about every measure it contained as well as adding new ones. “Most of the basic provisions of the law have not changed, but the text bears little resemblance to the one adopted by the government in October, 2014”, said Didier Tabuteau, head of the health chair at the school of political sciences in Paris, Institut d’Etudes Politiques de Paris, or Sciences Po. “It might not be the deepest health reform since World War 2, but it is certainly the widest, and has been like the best of American TV series, where constant new twists in the plot leave the audience breathless.”
French doctors protest over the health bill in November, 2015
831
World Report
approximately 70 authorised patients’ associations will be able to form a national federation to represent them in discussions with the government and administration, and whistleblowers signalling malfunctions in the healthcare system to the advisory National Authority for Health (Haute Autorité pour la Santé), such as doctors refusing to treat patients entitled to free consultations or problems with drugs, will be immune from sanctions. Another significant advance is stricter requirements to combat conflict of interest, said Laude. Until now, drug companies had only to publish the existence of contracts with medical practitioners and researchers, whereas now they will also have to disclose the fees they pay and the work involved. The Constitutional Council said the measure was an invasion of privacy, but justified it to protect public health, Laude added. The new law extends the new class action legislation to the producers and suppliers of health-care products, but she does not expect litigation on anything like the same scale as in the USA, as punitive damages do not exist in France. The law will also help clarify drug prices, often criticised for being too high, as approved patients’ associations will meet the price-setting body, the Economic Committee for Health Products (Comité Economique des Produits de Santé), three times a year to take stock of the decisions made since the previous meeting. “This should help revive public confidence in drugs, which has been seriously undermined in recent years, and will enhance associations’ understanding of what is entailed in developing and pricing drugs”, said Laude.
Raft of measures Other measures in the law include a single national telephone number to direct patients to a doctor on call, a 6-year pilot scheme for supervised injecting drug rooms, neutral cigarette packets (another huge source of friction), a ban on e-cigarettes in 832
public places, except for bars, cafés, and restaurants, and an end to the 7-day reflection period for abortions. The law also makes it compulsory for fashion models to show potential employers medical certificates giving their body-mass index to help avert anorexia, bans advertising for UV tanning centres and access for under-18s, brings in colour-coding indicating the nutritional value of food products, and gives homosexual and bisexual men permission to donate blood. Further, the law aims to widen access to the national public health database, which covers nearly all the
“...the law aims to widen access to the national public health database, which covers nearly all the population and is the most extensive medical archive in the world.” population and is the most extensive medical archive in the world. In addition to researchers, private sector companies, patients’ associations, and journalists will be granted access to it as long as their purpose is “in the public interest”. But the Collective of 42 health associations (Collectif Interassociatif sur la Santé) fears that controls to ensure patient anonymity and other precautions may be so strict that in practice the data will remain as inaccessible as ever, Secretary General Christian Saout said.
Other steps During the past year, Touraine has launched several initiatives outside the new law to try and ensure that the French health service keeps its reputation as one of the best in the world. These include incentives for generalists and specialists to practise in medically deserted rural areas, new rules for negotiating the price of reimbursable drugs with drug companies, and a €190 million 2015–18 plan for palliative and end-of-life care.
In addition, Touraine announced a plan to halt “unacceptable” vaccine shortages during the vaccination season, an overhaul of the work week and surgery departments in public hospitals, an increase in the budget for a fund for biomedical start-ups from €100 million to €340 million, and the merger of three health bodies into the National Public Health Agency (Agence Nationale de Santé Publique) to prevent problems and alert the authorities when these arise. “Change has accelerated in recent years, with globalisation, innovation, and digitisation”, said Laude. “This means that we constantly need new rules.” A major health conference was held on Feb 11 to discuss training, careers, and daily workloads in an effort to repair relations with the medical profession. Prime Minister Manuel Valls announced a series of measures to improve prospects, but the event was boycotted by the self-employed doctors unions who organised their own conference the same day in protest at the new law. On a wider front, France will launch a “major European offensive” on drug prices with an international conference hosted by President Hollande in Lyon in early April to discuss how to cut the price of new drugs, while guaranteeing drug companies’ return on investment and patient access. Although the new law was promulgated at the end of January, it will not fully take effect for several months until all the application decrees have been published. And that still might not be the final chapter. Apart from the threat of civil disobedience from practitioners, the three main potential candidates to represent the right-wing opposition party Les Républicains in the next presidential election—Nicolas Sarkozy, François Fillon, and Alain Juppé—have all said they will repeal part or all of the Touraine law if they win.
Barbara Casassus www.thelancet.com Vol 387 February 27, 2016
France passes wide-ranging health reforms After some turbulent months of protests by doctors and opposition by MPs, France has a new health law, bringing in a raft of new measures. Barbara Casassus reports from Paris.
Doctors’ dispute Anger over third party payments to be gradually extended to cover all patients by Nov 30, 2017, brought health professionals out on strike sporadically during 2015, but to no avail. The language introducing the measure was even tougher in the final text. Instead of just laying down the principle, and leaving it to practitioners and the administration to work out the details, the measure was made compulsory. Health Minister Marisol Touraine, who kept her job in the Feb 11 government reshuffle despite rumours to the contrary, “had hoped negotiations would be sufficient, but since the doctors’ unions all rejected the www.thelancet.com Vol 387 February 27, 2016
proposal, there was no choice but to impose it by law”, said Tabuteau. But that was not the end of the story. Taking up a complaint from more than 60 opposition parliamentarians from each of the two houses, the Constitutional Council ruled that third party payments for all would apply only to the national health and not to top-up private insurance. The text guaranteed doctors would be reimbursed within 7 days, but it said nothing about how President François Hollande’s promised “simple” mechanism for payment from France’s more than 500 health insurers would work.
population of 65 million who suffer long-term illness or undergo costly treatment and are taken fully in charge, he predicted. Overall, Tabuteau gives the law seven out of ten for what it includes, but much less for what it leaves out. “Nothing has been done to change the dual structure, whereby public hospitals report to the state and community practitioners report to the health insurance administration”, he said. “Nothing has been done either to iron out the huge inequalities in complementary health insurance”, he added.
“‘It might not be the deepest health reform since World War 2, but it is certainly the widest...’”
Positive steps
Touraine had hoped that the top-up payments issue would be remedied by the announcement of a streamlined system, that patients would demand third party payments for extra fees, and that doctors would offer it when they saw how straightforward the reimbursement process would be. And with presidential elections in 2017, note the cynics, Touraine would not risk upsetting health professionals again with a fresh attempt to push through unpopular legislation. But the unveiling of a dual public– private system to the profession on Feb 17 did nothing to quell doctors’ ire. Claude Leicher, president of MG France, the leading general practitioners union, said: “We are not against the principle of third party payments, but we need a one-stop shop for billing and reimbursements. Otherwise we would spend far too much time on paperwork.” The result of the dual system is that third party payments will be provided only to the 11 million patients out of the
By contrast, important steps have been taken to strengthen individual and patient association rights, said Anne Laude, director of the Graduate School of Law at the Paris-Descartes University, and co-director of the university’s Health and Law Institute. For the first time in France, people with cancer and other illnesses will have the “right to be forgotten” when seeking a bank loan or buying health insurance after 10 years in remission for adults and 5 years if the disease is diagnosed before the patient turns 18 years. The
Damien Meyer
France’s most voluminous health bill in living memory has finally become law, despite furious protests from the medical profession over plans to introduce third party payments for all, and a rap on the government’s knuckles in the final stages. The bill started out with just 57 articles, but after a 15-month passage through parliament ended up with 227 after both houses had adapted, amended, or augmented just about every measure it contained as well as adding new ones. “Most of the basic provisions of the law have not changed, but the text bears little resemblance to the one adopted by the government in October, 2014”, said Didier Tabuteau, head of the health chair at the school of political sciences in Paris, Institut d’Etudes Politiques de Paris, or Sciences Po. “It might not be the deepest health reform since World War 2, but it is certainly the widest, and has been like the best of American TV series, where constant new twists in the plot leave the audience breathless.”
French doctors protest over the health bill in November, 2015
831
World Report
approximately 70 authorised patients’ associations will be able to form a national federation to represent them in discussions with the government and administration, and whistleblowers signalling malfunctions in the healthcare system to the advisory National Authority for Health (Haute Autorité pour la Santé), such as doctors refusing to treat patients entitled to free consultations or problems with drugs, will be immune from sanctions. Another significant advance is stricter requirements to combat conflict of interest, said Laude. Until now, drug companies had only to publish the existence of contracts with medical practitioners and researchers, whereas now they will also have to disclose the fees they pay and the work involved. The Constitutional Council said the measure was an invasion of privacy, but justified it to protect public health, Laude added. The new law extends the new class action legislation to the producers and suppliers of health-care products, but she does not expect litigation on anything like the same scale as in the USA, as punitive damages do not exist in France. The law will also help clarify drug prices, often criticised for being too high, as approved patients’ associations will meet the price-setting body, the Economic Committee for Health Products (Comité Economique des Produits de Santé), three times a year to take stock of the decisions made since the previous meeting. “This should help revive public confidence in drugs, which has been seriously undermined in recent years, and will enhance associations’ understanding of what is entailed in developing and pricing drugs”, said Laude.
Raft of measures Other measures in the law include a single national telephone number to direct patients to a doctor on call, a 6-year pilot scheme for supervised injecting drug rooms, neutral cigarette packets (another huge source of friction), a ban on e-cigarettes in 832
public places, except for bars, cafés, and restaurants, and an end to the 7-day reflection period for abortions. The law also makes it compulsory for fashion models to show potential employers medical certificates giving their body-mass index to help avert anorexia, bans advertising for UV tanning centres and access for under-18s, brings in colour-coding indicating the nutritional value of food products, and gives homosexual and bisexual men permission to donate blood. Further, the law aims to widen access to the national public health database, which covers nearly all the
“...the law aims to widen access to the national public health database, which covers nearly all the population and is the most extensive medical archive in the world.” population and is the most extensive medical archive in the world. In addition to researchers, private sector companies, patients’ associations, and journalists will be granted access to it as long as their purpose is “in the public interest”. But the Collective of 42 health associations (Collectif Interassociatif sur la Santé) fears that controls to ensure patient anonymity and other precautions may be so strict that in practice the data will remain as inaccessible as ever, Secretary General Christian Saout said.
Other steps During the past year, Touraine has launched several initiatives outside the new law to try and ensure that the French health service keeps its reputation as one of the best in the world. These include incentives for generalists and specialists to practise in medically deserted rural areas, new rules for negotiating the price of reimbursable drugs with drug companies, and a €190 million 2015–18 plan for palliative and end-of-life care.
In addition, Touraine announced a plan to halt “unacceptable” vaccine shortages during the vaccination season, an overhaul of the work week and surgery departments in public hospitals, an increase in the budget for a fund for biomedical start-ups from €100 million to €340 million, and the merger of three health bodies into the National Public Health Agency (Agence Nationale de Santé Publique) to prevent problems and alert the authorities when these arise. “Change has accelerated in recent years, with globalisation, innovation, and digitisation”, said Laude. “This means that we constantly need new rules.” A major health conference was held on Feb 11 to discuss training, careers, and daily workloads in an effort to repair relations with the medical profession. Prime Minister Manuel Valls announced a series of measures to improve prospects, but the event was boycotted by the self-employed doctors unions who organised their own conference the same day in protest at the new law. On a wider front, France will launch a “major European offensive” on drug prices with an international conference hosted by President Hollande in Lyon in early April to discuss how to cut the price of new drugs, while guaranteeing drug companies’ return on investment and patient access. Although the new law was promulgated at the end of January, it will not fully take effect for several months until all the application decrees have been published. And that still might not be the final chapter. Apart from the threat of civil disobedience from practitioners, the three main potential candidates to represent the right-wing opposition party Les Républicains in the next presidential election—Nicolas Sarkozy, François Fillon, and Alain Juppé—have all said they will repeal part or all of the Touraine law if they win.
Barbara Casassus www.thelancet.com Vol 387 February 27, 2016