HEALTH SYSTEM

Government role

Statutory health insurance system, with all SHI insurers incorporated into a single national exchange.

Public system financing

Employer/employee earmarked income and payroll tax

Private insurance role

~95% buy or receive government vouchers for complementary coverage (mainly cost-sharing, some non covered benefits); limited supplementary insurance

Provider ownership

Primary care: Private

Hospitals: Mostly public (67% of capacity), some private for-profit (25%) and private not-for-profit

Provider payment

Primary care payment: Mix fee-for-service / pay-for-performance / flat EUR40 [USD48] bonus per year per patient with chronic disease and regional agreements for salaried general practitioners.

Hospital payment: Mainly case-based payments (includes physician costs in public hospitals but not in private) + non-activity-based grants for education, research, etc.

Primary care role

Registration with GP required: All patients older than 18 years of age are requested to register with a referring physician.

Gatekeeper: Voluntary but incentivized: higher cost-sharing for visits and prescriptions without a referral from physician registered with general practitioners or specialists.

HOW IS THE MEDICAL SERVICE ORGANIZED

Primary care

More than half of the physicians are fully or partially self employed. And more than half of the GPs (mostly the younger ones) work in group practices that generally consist of 2-3 physicians.
There is a voluntary (financially incentivized) gatekeeping system which foresees registering with a GP or specialist.
The self employed GP is usually paid through a fee for service.
The GP has specific quality targets which are officially imposed.

Outpatient specialist care

A majority of outpatient specialists are either fully salaried by a hospital or have a mixed income. Next to the quality targets which apply for the GP, the specialist needs to perform services within set disease related quality targets. The patient has generally freedom of choice after referral. Bypassing refers reduces the participation of the social security. Half of the specialists works in group practices. Hospital based specialists are allowed to see private patients.

Direct payments to providers

Patients are required to pay the full fee and claim for reimbursement. A third party payment mechanism (Système de tiers-payant) exists for the poorest population making the consultation fee of charge at the point of care.

After hours care

After hours care is provided by either the emergency department of an hospital (signed agreement with the regional health agency), self employed physicians working for emergency services and medical homes.
There is a national emergency phone number with trained professional that do the first line assessment of needed support.

Hospitals

There is a mix of private for profit, private non for profit and public hospitals, whereby the latter makes up for more than half of the facilities. Public hospitals are mostly funded by the statutory health insurance and to a lesser extend by private insurers or direct patient payments.

Mental Health Care

There is a strong emphasis on community based provision. Mental health care is not formally integrated in the primary care, nevertheless a large number of disorders are treated by GPs or private psychiatrists or psychologists on an outpatient basis. Statutory health insurance covers services provided by GP and Psychiatrist. Co-pays do not apply for patients diagnosed with long-term mental illnesses.

Long-term Care

Statutory health insurance covers medical costs of long -term care, but the families are carrying the housing costs in hospice and other long-term care facilities. End-of-life care in the hospital is fully covered.