The French National Health System

Image  France has an excellent, although expensive, national health system.  If you qualify for healthcare under the national health system, you and your family are entitled to subsidized or (in certain cases) free medical and dental treatment.  Benefits include general and specialist care, hospitalization, laboratory services, medicines, dental care, maternity care, appliances and transportation.  Those who don't automatically qualify can contribute voluntarily or take out private health insurance.

The reimbursement you receive from social security applies to the tarif de convention, which is not necessarily the same as the amount you pay.  For example, if a blood test costs E75 and the tarif de convention is E60, you would be reimbursed 70 per cent of E60 (E42) leaving you with a bill of E33.  The balance of medical bills, called the ticket modérateur, can be paid by a complementary health insurance scheme, to which many people subscribe. When choosing a medical practitioner, e.g. a doctor or dentist, it's important to verify whether he has an agreement (convention) with social security.  If he has an agreement, he's known as conventionné and will charge a fixed amount for treatment as specified under the tarif de convention.  If he has no agreement, he's termed non- conventionné and the bill may be two to five times that set by the tarif de convention; some non- conventionné practitioners are approved (agrée) by social security, but only a small proportion of their fees are reimbursed. 

A few medical professionals are classified as conventionné horaires libres; although they're conventionné, they're permitted to charge higher fees than the standard rates.  These include practitioners who perform specialist treatment (dépassement exceptionnel) and those with a particular qualification or expertise (dépassement permanent).  IF you're in any doubt, you should as what the fee is for a consultation or treatment and what percentage will be reimbursed by social security.

If you're non-resident you may be asked to pay in cash, although cheques drawn on a French bank are acceptable.  IF you're unable to pay your portion of the bill (the ticket modérateur), you can apply to your social security payment centre (Caisse Primaire d'Assurance Maladie/CPAM) for a waiver (prise en charge).  In the case of urgent or necessary treatment, approval is a formality,

If you're entitled to national health cover, you will be issued with an electronic credit-card-style card (carte à puce) called the Carte Vitale, which contains your social security number and covers all members of your family.  (Children under 16 are included on only one parent's card.)  A Carte Vitale is valid for three years and can be re-validated by machine in the town halls of most towns and cities.  At the end of 2006, the Carte Vitale will be replaced by the Carte Vitale 2, which will carry a photograph of the holder and will be linked to a computerized system known as a dossier médical personnel (DMP), containing all your medical records and vital information such as your blood group and allergies.  The idea behind the new system (like most health service innovations) is to save the government money by reducing a phenomenon known as nomadisme, whereby patients seek opinions on the same ailment from several doctors, which is estimated to cost E3 billion per year.

REIMBURSEMENT PROCEDURE
When you visit a medical practitioner whose fees are wholly or partly refundable by social security, simply present your Carte Vitale and reimbursement will be automatically ‘triggered', although you must still pay the doctor and wait for your bank account to be reimbursed.  (For some reason best known to French social security, doctors aren't paid by the system.)  Since 1st January 2005, E1 has been deducted from all reimbursements except those relating to treatment for children, women over six months pregnant and those on CMU, in order to reduce the social security debt.

If a medical practitioner isn't linked to the Carte Vitale system (or if he treats you at home or his computer is out of order), he will complete a treatment form (feuille de soins).  This may be one of several colours: for example, doctors use a brown and white form and dentists a green and white form.  The treatment provided and the cost of the consultation are listed on the form, which must be sent to your local CPAM for reimbursement.  Don't forget to sign and date the feuille de soins at the bottom right before sending it.  If forms aren't correctly completed, they will be returned. If medicines are prescribed, your doctor will also give you a prescription (ordonnance) for you to take to a chemist. 

An increasing number of chemists (pharmacists) have computer systems enabling them to deduct the appropriate percentage of the bill reimbursed by social security, leaving you to pay only the unreimbursed portion.  Some are also ‘linked' to certain complementary insurance schemes, so that once you've registered with the chemist, you won't have to pay anything.  Simply present your ordonnance to the chemist and the reimbursement procedure is taken care of for you.  If your chemist isn't computerized or doesn't recognize your complementary insurer, you must pay for your medicines and make a claim for reimbursement to social security and/or your complementary insurance policy later.  IN this case, the chemist will give you a copy of the feuille de soins, with confirmation that the medicines have been issued to you, for you to send to your CPAM or insurer (the CPAM may forward the details direct to your insurer).

If you're requesting a reimbursement for auxiliary services prescribed by a doctor, you must accompany the feuille de soins with a copy of the doctor's original prescription.  You can save a number of feuille de soins and send them together.

The refund will be paid directly into the bank or post office account that was designated when you registered with social security.  It's possible to receive payment in cash, although this isn't encouraged.  You will receive your reimbursement any time from a few days to a few weeks after application, depending on the office and the amount involved.  You will receive a statement from the office, confirming the amounts reimbursed to your account.  Normally, you will automatically receive reimbursement of the ‘complementary' sum (ticket modérateur) from your complementary insurance policy (sometimes before the social security refund).  If you don't, you must send the social security statement to your complementary insurer.  Always keep a copy of your feuilles de soins and check that reimbursements are received and correct.

 To be reimbursed by social security for certain medical treatment, you must obtain proper approval from your CPAM.  This may include physical examinations, non-routine dental care, contact lenses and non-standard lenses for glasses, certain laboratory and radiology tests, physiotherapy and speech therapy, and thermal and therapeutic treatments. Your medical practitioner will give you a proposal form (demande d'entente prélable) and, unless treatment is urgently required, you should apply at least 21 days before the proposed treatment  and obtain a receipt for your application (if made in person) or send it by registered post.  If you don't receive a reply from your CPAM within ten working days, it's deemed to have agreed to the request.

DOCTORS
There are around three doctors (médecins) per 1,000 population in France (compared with 1.7 in the U.K., 4.4 in Spain and 5.9 in Italy), around 45 per cent of them women, and there are excellent doctors throughout the country, although finding a doctor who speaks good (or any) English can be a problem, particularly in rural areas.  Many embassies and consulates maintain a list of doctors and specialists in their area who speak English (and other foreign languages), and your employer, colleagues or neighbors may be able to recommend someone.  Town halls and chemists keep a list of local practitioners.  You can obtain a list of doctors registered with social security from your local social security office.  General practitioners or family doctors (médecin généraliste) are listed in the yellow pages under Médecins Généralistes and specialists under Médecins Qualifiés followed by their specialty, e.g. Gynécologie Médicale.  (There are as many specialists as general practitioners.)  All French doctors and specialists are registered with the Ordre des Médecins.
Until recently, you could choose to see any doctor or specialist at any time and weren't required to register with a particular doctor, which made it easy to obtain a second opinion, should you wish to do so.  You're now required to appoint an ‘acting doctor' (médecin traitant) and to obtain a referral from him before seeing another doctor or specialist, including a medical auxiliary such as a nurse, physiotherapist or chiropodist, or a gynecologist, ophthalmologist or pediatrician.

 Many French doctors are specialists in acupuncture and homeopathy, both of which are reimbursed by social security when performed or prescribed by a  doctor or practitioner who is conventionné.  It's normal practice to pay a doctor or other medical practitioner after each visit, whether you're a private or social security patient.  A routine visit to the doctor costs E20 (E25 for treatment to a child); home visits cost more (e.g. E40).

 The standard fee for a consultation with a specialist is E25, but visit to a psychiatrist, neuro-psychiatrist or neurologist will cost you E37, and specialists who are non-conventionné can charge E45 or more.

Many doctors are in single practices but an increasing number work in group practices, and there are also healthcare centres (centre médical et social) which may offer services that are usually unavailable at doctors' surgeries, e.g. health screening, vaccinations, dental care (soins dentaires) and nursing care (soins infirmiers).  Some centres specialize in a particular field of medicine, such as cancer or heart treatment.  For example, as part of a Health Department initiative to fight breast cancer, women aged between 50 and 74 can obtain free screening (dépistage) at centres listed on ww.rendezvoussanteplus.net.  Although it isn't always necessary to make an appointment5, it's preferable (unless you like waiting for hours).  As when visiting a doctor, check whether the centre is conventionné.  In some areas, there are outpatient services (centre de soins) run by private organizations such as the Red Cross.  You can obtain a list of local healthcare centres from your town hall.

MEDICINES
The French take a lot of medicines (médicaments - drogues are narcotics!) and are Europe's largest consumers of sleeping pills, tranquillizers and anti-depressants such as Prozac and Valium.  Medicines prescribed by doctors represent over 80 per cent of sales, and doctors habitually prescribe three or four different remedies for each ailment.  The French have traditionally been prescribed more  antibiotics than any other Europeans, a third of which are reckoned to be unnecessary or ineffective, and have the highest incidence of anti-biotic-resistant bacteria in Europe, with the result that the government is now campaigning (among both doctors and patients) for a reduction in antibiotics prescription.  The cost of prescription medicines is controlled by the government (prices are reviewed twice a year), although there are no price controls on non-prescription medicines,


Social security pays the whole cost of essential medication for certain illnesses or conditions, e.g. insulin and heart pills, (labeled ‘100 per cent') 65 per cent of medicines designated as important (with white labels) and 35 per cent for médicaments de confort (with blue labels).  A few medicines aren't reimbursed at all, including most contraceptive pills.  Note that medicines deemed to be ‘ineffective' won't be reimbursed at all.  The complete list of ‘ineffective' medicines can be found on http://agmed.sante.gouv.fr  If you must pay for your own medicines, it can be expensive, e.g. E100 or more for a course of antibiotics.

The brand names for medicines often vary from country to country, so if you regularly take a particular medicine you should ask your doctor for the generic name.  IF you wish to match a medicine prescribed abroad, you need a current prescription with the medicine's trade name, the manufacturer's name, the chemical composition and the dosage.  A chemist may propose a generic product which is cheaper than the brand on your prescription (as part of the government's scheme to reduce health spending) but you aren't obliged to accept the alternative product. Note, however, that under legislation which became effective in July 2003 social security reimbursement is based on the generic equivalent of branded medicines (if one exists).  Generic products, which are up to a third cheaper than branded products, are usually identified by the prefix ‘Gé'.  Most foreign medicines have an equivalent in France, although particular brands may be difficult or impossible to obtain.  It's possible to have medicines sent from abroad and no import duty or value added tax (TVA) is payable.  If you're visiting France for a short period, you should take sufficient medicines to cover the length of your stay.  In an emergency, a local doctor will write a prescription (ordonnance) that can be filled by a local chemist, or a hospital may refill a prescription from its own pharmacy.

HOSPITALS AND CLINICS
France boasts a higher number of hospital beds in proportion to its population than most other European countries (8.7 per 1,000 compared with 7.6 in Spain and Italy and 6.9 in the UK), although the introduction of the 35-hour week and a recent shortage of doctors and nurses, particularly in the provinces, have led to the closure of many wards, and in the summer months, when staff are on holiday, some hospitals are forced virtually to close.  There's also a shortage of certain specialists, e.g. anesthetists, gynecologists and ophthalmologists, partly due to a recent increase in malpractice lawsuits,


All cities and large towns have at least one hospital (hôpital) or clinic (clinique),indicated by the international hospital sign of a red ‘H' on a white background.  Hospitals are listed in the yellow pages under Hôpitaux et Hospices.  There are many types of hospitals, both public and private.  Like doctors and other medical practitioners, hospitals are either conventionné, or non-conventionné.  Every large town has at last one hôpital conventionné, which may be public or private, usually wit ha direct payment agreement with social security.   

Private hospitals and clinics that are non-conventionné may also have an agreement (agréé) with social security, whereby around 30 per cent of the fees are usually paid by social security.  For non-urgent hospital treatment, check in advance the reimbursement made by social security and, if applicable, the amount your complementary insurance policy or other private health insurance will pay.  IF you're admitted to a hospital or other medical institution, you should be given a document outlining your rights (charte des droits et libertés).

PUBLIC HOSPITALS
There are generally three categories of public hospital: hospital centres or short-stay hospitals (hôpital de court séjour), medium stay centres (centre de moyen séjour) and long term treatment centres (centre et unité de long séjour).  Hospital centres incude general hospitals, assistance publique (AP) hospitals in Paris, specialist hospitals and regional centres (centre hospitalier régional/CHR or centre hospitalier universitaire/CHU when associated with a university).  Public hospitals must accept all patients in an emergency irrespective of their ability to pay.

Medium stay hospitals are usually for patients who have previously been treated in a short-stay hospital centre.  They contaiun facilities for convalescence, occupational and physical therapy, and recuperative treatment for drug and alcohol abuse and mental illness.  Long-term treatment centres are for those who are unabl to care for themselves without assistance and include psychiatric hospitals and nursing homes for the aged (maisons de retraite).

There are over 35 CHUs in France (12 in Paris), where medical students do their training.  CHUs are reated among the best hospitals in France (indeed in the world), and professors and senior staff must undergo intensive training to seucre their appointments.  Rural community hospitals are also classified as hospital centres, although they're usually less well equipped than other short-stay hospitals and you should go to a large hospital if possible. Not all hospitals have accident and emergency (urgences) departments, and you should check wehre your nearest A&E centre is to be found.

PRIVATE HOSPITALS AND CLINICS

Most private hospitals (hôpital privé) and clinics (clinique) specialize in inpatient care in particular fields of medicine, such as obstetrics and surgery, rather than being full-service hospitals.  (the American Hospital in Paris is a rare exception).  You should check in advance.  The cost of treatment in a private hospital or clinic is generally much higher than in a public hospital, where a large proportion of costs are reimbursed by social security.  However, some private hospitals participate in the French social security system and operate in the same way as public hospitals.  These include the Hertford British and International hospitals in Paris.


If your French is poor, you may prefer to be treated at a private hospital or clinic with English-speaking staff, as most public hospitals make little or no allowance for foreigners who don't speak French.  There are a number of expatriate hospitals in the Paris area, including the American hospital in Paris (63 boulevard Victor Hugo, 92200 Neuilly, 01 46 41 25 25 or 01 47 47 70 15 for emergencies, www.american-hospital.org) and the Hertford British Hospital, known as the Hôpital Franco-Brittanique (3 rue Barbès, 92300 Lavallois-Perret, 01 46 39 22 22), which specializes in maternity care.  Most staff at all levels in these hospitals speak English.  Fees at the American hospital are much higher than at French hospitals, although they can usually be reclaimed through the French social security system and most mutuelles and are accepted by most American medical insurance companies.

Excerpted from "Living and Working in France" It can be purchased from Survival Books

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