This presentation was made by Ayden TAJAHMADY, France, at the 5th Meeting of the joint OECD DELSA/GOV Network on Fiscal Sustainability of Health Systems held on 4-5 February 2016 at the OECD Conference Centre in Paris.

1. 1February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Performance information and health
system efficiency in France
CNAMTS
(National Health Insurance Fund for salaried workers)
Ayden Tajahmady – Grégoire de Lagasnerie
Deputy director of the Division of Statistics and Strategic research

2. The two ways to implement performance budgeting
2
 The French health care system:
• Centralized health insurance system
• Main issues:
– High Health expenditure as a share of GDP, 2013 : 10,9% (6th OECD country)
– Medical practice variation
– Equity
 Change stakeholders’ behaviors to improve efficiency:
1. Financial incentives towards main health care system’s stakeholders
(professionals, structures and patients)
2. Non Financial incentives thanks to huge data collection: increase
stakeholders’ empowerments to implement medico-economic
management
February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

3. Main challenge : Making sense of the huge amount of data collected to improve efficiency
3
Source: http://networkingnerd.files.wordpress.com/
February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Political
decision
Health care
professionals’
management
tools
Patients’
empowerment
Indicators

4. 4February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Data and political decision

5. Data and political decision
5
 One of the Medico-administrative database in France :
• National Health Insurance Information System (SNIIRAM): exhaustive
anonymous data about >60 millions individuals
• Information available on ambulatory care (drugs, medical visits and
procedures, biological tests, dental care, ...), inpatient care, payment for
sick leave,...
• Daily reimbursements follow-up
 Use of the data for policy decision-making
• Improve healthcare pathways
• Contribute to a better management of the health insurance
• Contribute to a better management of health policies
• Provide healthcare providers with relevant information relative to their
activity, receipts and prescriptions
February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

6. e.g. Describe the health inequalities due to socioeconomic status in
2013 (a geographic index of deprivation)
6February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Source : SNIIRAM/EGB-PMSI, 2013
2% 3%
4%
6%
8%
11%
14%
20%
26%
35%
42%
48%49%
3%
5%
7%
10%
13%
17%
21%
27%
32%
39%
45%
48%
45%
0%
10%
20%
30%
40%
50%
Age groups
Prevalence of polypathology
1 (10% les plus favorisés)
2
3
4
5
6
7
8
9
10 (10% les plus défavorisés)
10 % most well-off
10 % least well-off

7. Map the burden of disease and their costs in France
7February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Source : SNIIRAM/EGB-PMSI, 2013
Cardiovascular
diseases, acute
Cardiovascular disease,
chronic
Treatment of vascular risk
factors (no CVD)
Diabetes
Cancers, active
Cancers, surveillance
Psychiatric diseases
Psychiatric treaments
Neurologic diseases
Chronic
respiratory
disease
Inflammatory or rare
diseases or HIV
Diseases of the
liver or pancreas
Maternity
Isolated hospitalisation
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
0 2,000 4,000 6,000 8,000 10,000 12,000
Numberofpatients
Average cost per patient (€)

8. Medicalized approach of expenditure to target specific policies on costly disease: Sick
leave
8February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Source : SNIIRAM/EGB-PMSI, 2013
22%
3%
6%
6%
5%
5%
28%
25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Soins courants/traitements antalgiques ou anti-
inflammatoires
Hospitalisations ponctuelles (avec ou sans pathologies,
traitements ou maternité)
Maternité (avec ou sans pathologies)
Autres
Cancers
Diabète (avec ou sans pathologies) ou traitements du
risque vasculaire (hors pathologies)
Maladies cardioneurovasculaires
Maladies psychiatriques ou psychotropes
Basic care and treatments with pain killers
Isolated hospitalisations
Maternity (maternity leave excluded)
Others
Cancer
Diabetes and other vascular risk treatments
Cardiovascular diseases
Psychiatric diseases or treatments
Total 10,2 Billion out of 147 Billion € (7%)

9. 9February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Data and health care professionals management tools

10. Data and health care professionals’ management tools
10February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Financial tools:
P4P
Non-financial tools:
benchmark and information
Hospital
Financial incentives for quality
improvement (IFAQSS)
• Pilot phase
• Quality : assessing pain, screening
for denutrition…
• Reward : 0 to 0.5 % of previous
year budget
Web platform
(http://hospidiag.atih.sante.fr/)
• Activity, Quality,
• Organization, Human resources
• Finance
Outpatient
Financial incentive for public health
targets (ROSP)
• Generalized since 2011
• 29 indicators (organization,
chronic disease follow-up,
prevention, efficiency)
• 1300 points / 7€ per point
• In 2014, av. 5,900 € / GP
• Total expenditure : 376 M€
Medicalized management of
spending (maîtrise médicalisée)
• Any prescirption is eligible (drugs,
physiotherapist, sick leace…)
• Information and benchmark is
procided according to
prescription profile
• Prior authorization schemes are
possible

11. Global surgical performance of my hospital ?
11February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Source : ANAP - ATIH © 2015-2016

12. Global financial performance of my hospital?
12February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Source : ANAP - ATIH © 2015-2016

13. Medicalized management of spending (maîtrise médicalisée)
13February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Interview with
high
prescribing
(drugs, cash
allowances…)
physicians to
give them
some data
about their
activity in
comparison
with « same »
physicians

14. 14February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Data and patients’ empowerment

15. Data and patients’ empowerment : increase competition between providers
15
 Lack of information for patients is one of the main cause of inequality in
the health care system
 Collection of data should be used to inform patients about the quality of
care…
• Reluctance from professionals to be ranked and compared according to
subjective indicators
 Some tools exist but there is still a large scope for further improvements
• www.annuairesante.ameli.fr/ : information about average costs of different
medical procedures billed by the health professional
• http://www.scopesante.fr/ : Help to choose an hospital through
organizational and quality indicators (nosocomial illness, organization)
February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

16. Increase competition between health care providers by circulating average
costs in function of the type of care
16
 E.g. Choose a dentist: a type of care associated with high out-of-
pocket
• Dentist A’s tariff for tooth crown on dental implant
• Dentist B’s tariff for tooth crown on dental implant
February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
Source : www.annuairesante.ameli.fr/

17. 17
February 2016 - CNAMTS - DELSA GOV meeting on
sustainability of Health systems
Conclusion: how does it contribute to increase the efficiency of
the health care system?

18. Conclusion
18
 Difficult to evaluate the impact of these tools…
• For instance: difficulty to estimate the impact of P4P programs
 But they may have an impact on patients’ and professionals’ behaviors
in mid or long term
 To go further:
• Political decision
– Health law 2015: Open data for database without risks of re-
identification (increase access for researchers to evaluate of health
policies …)
• Health care professionals’ management tools and patients’ empowerment
– E-Satis: online satisfaction survey after hospital discharges
February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

19. 19
Thank you for your attention !
February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

20. 20February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
 Annex: The French health care system in a nutshell

21. 21
February 2016 - CNAMTS - DELSA GOV meeting on
sustainability of Health systems
The French health care system in a nutshell
Source : Health at a glance 2015

22.  Outpatient care :
• Majority of general practitioners and specialists
• Fee for services with private practice for physicians
• Pay for performance
• Freedom of establishment for physicians and weak gatekeeping
 Inpatient care :
• Majority of DRG payment + Global budget for specific missions
(teaching, research, emergency care)
• All hospitals are financed by the public health insurance but
managerial autonomy for hospital director
• Majority of public beds (62% of public beds, 14% of private not
for profit beds, 24% of private for profit beds)
Supply side
22February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

23. Health expenditure and financing
23February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
 Expenditures :
• Health expenditure per capita, 2013 : 4124 USD PPP (12th
OECD country)
• Health expenditure as a share of GDP, 2013 : 10,9% (6th OECD
country)
– High share of impatient care : 35% (3rd OECD country)
 Financing :
• Centralized health insurance funds financed by taxes and
social security contributions : 79%
• Private complementary insurance financed by premiums :
14%
• Out-of-pocket : 7%