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which account for 37 percent of all short-stay

insurance payments means that nongovern-

hospital beds and half of all surgical beds, con-

ment sources account for roughly 20 percent

trol their own budgets, whereas public hospi-

of all health care spending, less than half the

tals operate under global annual budgets

amount spent in the United States but still

imposed by the Ministry of Health.

more than most countries with national

health care systems.56

Health care technology that the National

Health Authority has categorized as "insuffi-

The private insurance market in France is in

cient medical service rendered" cannot be pur-

many ways less regulated than the U.S. market.

chased by public hospitals, and its use at cliniques

For example, while 20 U.S. states require some

is not reimbursable through national insurance

form of community rating or put limits on

schemes.61 Yet in denying reimbursement for

health insurance premiums, private health

insurance in France is largely experience rated.

such technology, the French government

No regulations specify what benefits must be

admits that when a product with an insufficient

included in coverage or mandate "guaranteed

medical service rendered is de-listed from reim-

issue"; and pre-existing conditions may be

bursement, this does not imply that it is not effi-

excluded. The only significant restriction

cient for a given pathology, but simply that the

requires "guaranteed renewability" after two

government prefers to commit its resources to

years of coverage.57 More than 118 carriers cur-

other reimbursements which it deems more

useful from a collective point of view."62

rently offer some form of private health insur-

ance coverage.58

In general, the quality of French health care

is high, but there are problem areas. Until very

In general, French patients pay up front for

recently, the French have generally had quick

treatment and are then reimbursed by their

access to their primary care physician of

government health insurance fund and/or pri-

choice. Now, a growing problem, nomadisme

vate insurance. The amount of reimburse-

medical, wherein patients go from one doctor

ment, minus the copayment, is based on a fee

to another until they find one whose diagno-

schedule negotiated between health care

sis they prefer, is driving up costs to the sys-

providers and the national health insurance

tem.63 The government has responded by

funds. These fee schedules operate similarly to

the diagnostic-related groups (DRGs) under

increasing copayments and attempting to

the U.S. system.

limit physician reimbursements.

Although reimbursement levels are set by

Much of the burden for cost containment

the government, the amount physicians charge

in the French system appears to have fallen on

is not. The French system permits providers to

physicians. The average French doctor earns

just €40,000 per year ($55,000), compared to

charge more than the reimbursement sched-

€

ule, and approximately one-third of French

$146,000 for primary care physicians and

physicians do so.59 In some areas, such as Paris,

$271,000 for specialists in the United States.

This is not necessarily bad (there is no "right"

the percentage of physicians who bill above

income for physicians) and is partially offset by

reimbursement schedules runs as high as 80

percent.60 In general, however, competition

two benefits: 1) tuition at French medical

schools is paid by the government, meaning

prevents most physicians from billing too far

French doctors do not graduate with the debt

outside negotiated rates; and physicians

burden carried by U.S. physicians, and 2) the

employed by hospitals, as opposed to those in

The private

French legal system is tort-averse, significantly

private practice, do not have the same ability to

insurance market

reducing the cost of malpractice insurance.64

charge more than the negotiated rate.

in France is in

The government also sets reimbursement

The French government also attempts to limit

rates for both public and private hospitals,

the total number of practicing physicians,

many ways less

which are generally not allowed to bill beyond

imposing stringent limits on the number of

regulated than

the negotiated fee schedules. While fees are

students admitted to the second year of med-

ical school.65

the U.S. market.

restricted, private hospitals (called cliniques),

9