Each year, la Sécurité Sociale determines the national fixed fees for pharmaceuticals, primary, specialist, hospital and dental care.
Most healthcare services in France are reimbursed on a fee-for-service basis based on Diagnosis Related Group (DRG), however this is starting to change.
Both public and private providers are on a fee-for-service rate by the government, calculated by diagnosis, procedure or service. Patients accessing health services are reimbursed by their public health insurance fund between 80-100% of that national fee, regardless of whether they access services from a public or private provider. However, private doctors maycharge patients a higher fee than the state-determined rate. Hence, a large proportion of the population (approx. 90%) has additional private health insurance to cover any gap.
Doctors are categorised into three sectors that describe the fee-for-service they charge. Sector 1 doctors charge the national fixed fee and the patient will be reimbursed 80-100% of that fee each time they access the service. Most GPs are in this category. Sector 2 doctors are approved to charge a higher rate with “reason”. Patients are reimbursed 80-100% of the national fixed fee and pay the gap using private health insurance or a self-funded co-payment. Most specialists are in this category. Sector 3 doctors have no fee limit. These are usually doctors practising in highly specialised areas of medicine.
Hospital fees (public and private) are set by the central government at a fixed rate per patient (based on DRG) to cover the fixed costs of clinical facilities, administration, nursing care and hotel services. Public hospitals are also paid per patient (by DRG) but at a rate 20% higher than the private hospitals. Public hospitals also receive additional dedicated funds for activities not directly related to individual health service delivery, such as research and training.
Private hospitals charge patients an additional fee if they choose to access a private room or extra hotel services, and this is usually covered by the patient’s private health insurance or self-funded. Private hospitals will also receive additional income from specialists who pay the hospital for use of their facilities (ie. theatres, consulting rooms) and for the provision of administrative services. This is a negotiated rate and based on a percentage of the specialist’s income and the level of additional services they access from the hospital (such as consultation rooms, administrative support etc.).
Mental health
The national government has introduced a value-based model in which healthcare providers are reimbursed based on the value they provide to patients, rather than the volume of services they provide.
Mental health services (from 2022) and Rehabilitation services (from 2023) are funded using a tiered fee structure based on day-rate, population allocation (based on socio-economic status and patient acuity within that region) and quality outcomes (reported patient clinical outcomes and experience).
