Access to Health Services for the Poor and Underserved in France

Transcription

1 Access to Health Services for the Poor and Underserved in France Enquête sur l accès aux soins des défavorisés ( ) Thérèse Lecomte, Nathalie Meunier, Andrée Mizrahi, Arié Mizrahi, Valérie Paris, Marie-Jo Sourty-Le Guellec

2 - 1 - Access to health services for the poor and underserved in France France: 551,000 km²; population: 58 million. 26% are under 20 years old; 15% are 60 years and over. Life expectancy: men: 74 years; women: 82 years. GDP per person: 131,990 FF in Unemployment rate: 11.6% of active population. Long-term unemployed: million. An estimated 300,000 persons are homeless, marginalized and unable to claim their right of access to social security. French health insurance covers 70% of health expenditure The French health care system is based on universal compulsory health insurance, significant patient cost-sharing, and supplementary insurance. About 99% of the population are covered by the statutory insurance scheme. Coverage is employment based. Contributions to insurance are income related and are shared by employers and employees or paid directly by non salaried individuals. Patients may be required to make copayments. Some employers provide supplementary insurance for their employees through mutual fund organizations to cover patient copayments. Individuals may also subscribe to private supplementary insurance. Out-of-pocket payments currently account for around 14% of national health expenditure. An estimated 87% of the French population are covered by both compulsory and supplementary health insurance. Deteriorating social context The current high unemployment rate (12%) is worrying as it implies further social deterioration. Theoretically, unemployed people are still covered by the insurance scheme. However, marginalization and homelessness often render them unable to claim their right of access. Furthermore, an increasing proportion of those on low incomes, while receiving mandatory coverage, cannot afford to advance payment for care which will be reimbursed later. They can neither afford copayments nor supplementary insurance. As a result, a growing number of persons cannot afford to use the normal care system. Faced with this deteriorating situation, parallel care delivery systems have been introduced at a local level, facilities have been created, with health care providers volunteering to deliver health care to the underserved.

3 - 2 - CREDES has carried out a national survey specifically to estimate the extent of the phenomenon In , CREDES carried out a two-step specific survey to study the impact of poverty on access to health care. The fringe population usually slips through the net of traditional surveys and they must be approached indirectly. We began by identifying health care providers and facilities actually accessible to the underserved. These include traditional providers or facilities, such as physicians and hospitals, which agree to provide charity care. There are also new facilities created specifically to provide the underserved with health care. The second part of the survey covered the human resources, equipment and services offered at these specific facilities. Survey design First step: hostels and day-centers for the homeless and information offices were targeted aim: to assess the health care facilities made available for the uninsured and those unable to pay. data collected: health care resources used when residents or visitors need care. participation in survey: 661 valid questionnaire returns (representing a 37% response rate). result: an inventory of health care centers specifically for the disadvantaged. Second step: health care centers specifically for the disadvantaged were targeted aim: to assess human and material resources existing outside the traditional system. data collected: quantitative data on medical and paramedical staff, facilities and patients. participation in survey: 171 specific centers responded. findings: extensive participation by physicians and nursing staff generally on a voluntary basis. Attention given to reintegrating them into the standard health care system through assistance with the necessary administrative procedures.

4 - 3 - Graph 1 Out-of-pocket payments currently account for around 14% of health expenditure % of persons covered compulsory cover supplementary cover Source : Enquêtes décennales sur la santé /1980/ Enquête Santé et protection sociale Graph 2 Steadily rising unemployment Unemployment rate and percentage of people receiving the minimum social security allowance between 1960 and 1995 in France 14% 12% 10% 8% 6% 4% 2% 0% Source : Chômage (INSEE), RMI (CNAF) unemployment minimum social security allowance

5 - 4 - Graph 3 Inability to pay (even if part of this amount will be reimbursed) prevents some households from taking advantage of certain types of health care Percentage of persons renouncing certains types of health care for financial reasons 25,3 global less than 12 months 15 16,3 % of persons 10 13,8 8,9 5 4,9 3,4 6,8 4,3 4,6 2,4 0 Dentitry Glasses Medical care, tests Other Global CREDES - ESPS 1995 Graph 4 Health care resources used when residents or visitors need care, by type of care pharmaceuticals dental care psychiatric care nurse care medical care no solution internal center for underserved dispensary psy day center hospital GP Standard health care facilities are often used. Physicians in general practice provide the disadvantaged with care free of charge on an ad hoc basis. Hospitals provide reception facilities, where these patients can be sent to the appropriate department for treatment free of charge. However, specific centers are being set up throughout the country Source : Enquête sur l'accès aux soins des défavorisés - CREDES

6 - 5 - Graph 5 Time needed for complete formalities % of centers providing assistance for formalities % centers helping with formalities less than 8 days 8-15 days days one month and over Help with administrative formalities, to allow access to the standard health care system. Hostels, day-centers and information offices provide help with the administrative formalities needed for access to the standard health system hostels day-centers others status unknown Source : Enquête sur l'accès aux soins des défavorisés - CREDES Graph 6 Physicians and paramedics work on behalf of the underserved, essentially on a voluntary basis other paramedics 18 volunteer paramedics 462 centers : 158 patients : 3747 patients needing medical care : 2544 patients needing paramedical care : 1850 salaried paramedics 170 other physicians 16 volunteer physicians 807 salaried physicians Source : Enquête sur l'accès aux soins des défavorisés - CREDES

7 - 6 - The survey covered 158 health care centers specifically for the underserved throughout France : 3747 patients were seen during a 7-day period Nord: 5 centers 149 patients 21 physicians 14 paramedics Ouest: 21 centers 425 patients 124 physicians 85 paramedics Ile-de-France: 10 centers 433 patients 28 physicians 23 paramedics Bassin Parisien: 25 centers 541 patients 92 physicians 65 paramedics Est: 18 centers 264 patients 105 physicians 48 paramedics Centre-Est: 26 centers 465 patients 149 physicians 124 paramedics Sud-Ouest: 20 centers 403 patients 80 physicians 62 paramedics Provence-Côte d Azur-Corse: 33 centers 1067 patients 347 physicians 229 paramedics