Healthcare system overview
The healthcare system in France comprises a fully integrated network of public hospitals, private hospitals, doctors and other medical service providers. It is a universal service providing healthcare for every citizen, irrespective of wealth, age or social status.
The system is funded from four sources:
- Obligatory health contributions are levied on earned income, which is paid by employers, employees and the self-employed
- Obligatory contributions levied on unearned income (investment income, pensions, etc)
- Central government funding
- Users who normally have to pay a small fraction of the cost of the healthcare that they receive.
In European terms, the French healthcare system is one of the better funded in terms of gross domestic product (GDP), and average in terms of general practitioners (GP), hospital beds and nursing professionals. A&E services (les urgences) are part of the national heathcare system. In France, emergency medical services are provided by a mix of organisations under public health control. The central organisations that provide these services are known as a SAMU (Service d'Aide Médicale Urgente – Urgent Medical Aid Service). SMUR (Service Mobile d’Urgence et Réanimation – Mobile Emergency and Resuscitation Service) refers to the ambulances and response vehicles that provide advanced medical care.
Helicopter Emergency Medical Services are provided by the government and under contract to Babcock, which operates from 28 bases across the country, owns and maintains a fleet of 35 specialist emergency medical service (EMS) aircraft and provides specialist medical crews and aircraft engineers.
Access to French Healthcare system for non-residents
Temporary visitors to France from the EU/EEA/Switzerland can access public healthcare if they have a European Health Insurance Card (EHIC) card; and since 2021, visitors from the UK can access public healthcare if they have a Global Health Insurance Card (GHIC) – which replaced the EHIC after Brexit – although their EHIC will be valid until the expiration date of the card.
Generally, medical care in France is not free at the point of delivery – the patient is required to pay and later obtain reimbursement on presentation of a receipt called a feuille de soins; usually around 70 per cent of the costs, sometimes less for prescription medications and laboratory tests. Usually up to 80 per cent of the cost will be reimbursed for inpatients. However, some expenses such as private rooms or a television will not be covered, so for travellers, having a travel insurance policy is still recommended even if they are also eligible for an EHIC or GHIC.
Louise Heywood, General Manager of the International Assistance Group (IAG), noted: “The level of reimbursement of dental care in France is also low, so if emergency dental care is necessary it is recommended to have travel insurance that will cover it.”
She added: “Finding a doctor in France is not difficult, although having some knowledge of the French language does make using the online systems such as ameli or doctorlib easier. Contacting the insurer’s assistance company will make it easier [for the client] as they are likely to have preferred doctors in most locations whom they know will have good English skills for non-French speakers including access to private 24/7 medical emergency services which can send a doctor to a home or hotel instead of using an ambulance.”
Providing international patient services
Specialist healthcare is provided by thousands of specialists in all branches of medicine in towns and cities throughout France. Specialists charge higher fees than GPs – but again there are official rates agreed with the national health service, which form the basis on which patients are reimbursed. A large number of specialists apply tariffs that are higher than the official rates; in such cases, patients will either be reimbursed according to the standard rate, or else at a higher rate, if their health insurance provider provides for this.
There are two sorts of hospitals in France; generally speaking, these are known as hôpitaux when they are state run, and cliniques when they are privately run. Most private cliniques are state-approved, and can therefore work for the national health service. Many specialists work in both state-run hospitals and in private clinics; since they are self-employed professionals, they can sell their services to whatever hospital or clinic will pay them.
Dr Issam Badaoui, Senior Medical Director, Medevasan, spoke to ITIJ about what insurers with clients in French hospitals need to know about the system: “The difference between the French healthcare and medical assistance market and the others in Europe is the following: in France there is an undeveloped billing system in public facilities – in hospitals, there can be an absence of a billing department staff after business hours; the department may also limited in their English capabilities within the staff. There can also be a long wait to get appointments, but there is easy access to emergency department of the public hospital even if the patient doesn’t have a way to pay.”
He continued: “In terms of billing in public hospitals, we don’t face big challenges, the medical expenses are usually accurate. However, placing a guarantee of payment (GOP) is often a challenge, especially for foreign companies that don’t have French language abilities; and after business hours you need to have a good network, otherwise you will face discontinuity in terms of acceptance between various people from the billing department.
Private hospitals often are part of large groups like Ramsay (former Générale de Santé), Almaviva, Elsan, among others. Outside of that, in more rural areas, facilities are more likely to be public, smaller and without the full range of departments and treatments
“There are limited providers with a 24/7 English speaking staff monitoring the key steps of the mission. Unfortunately, there are plenty of providers that don’t have the right operation to match the requirements or the expectations of international companies; very few will be able to cover most of the country.”
Louise Heywood of IAG noted: “Private hospitals often are part of large groups like Ramsay (former Générale de Santé), Almaviva, Elsan, among others. Outside of that, in more rural areas, facilities are more likely to be public, smaller and without the full range of departments and treatments.” She agreed that it can be challenging to find English-speaking staff, both medical and administrative. She added: “They are often unlikely to have an international billing department or experience with foreign patients.”
And this, of course, is where the role of assistance companies with experience of working with international payers come in.
The evolution of assistance services
France pioneered the sector of assistance companies with the creation of Europ Assistance by Pierre Desnos in 1963 with the support of Generali. Mondial, now part of AXA and Allianz, are also well established. Over 10,000 workers are employed in the assistance industry in France.
The Syndicat National des Sociétés d’Assistance (SNSA) was created in 1981. Its nine members represents 97 per cent of French assistance providers, and defends the interests of the profession. The International Assistance Group (IAG) was formed in 1992 to help smaller, independent assistance companies provide reciprocal services, share provider networks and reduce costs of developing and managing global providers.
High salaries mean high costs in air medical services
Paul Tiba, Managing Director of Airlec Ambulance in Bordeaux, France, pointed out one particular aspect of the French healthcare system of which international payers should be well aware: higher rates of pay. “One major factor that is challenging for providers are the extremely high costs for salaries of pilots and medical crew alongside the very strict regulations regarding employment and hospital work. Airlec, for example, employs all of its medical staff – including its flight doctors – as direct employees, as required by French law. Unfortunately, like in many other countries, staff shortages are currently a huge issue on both sides – medical crews and pilots – which has been a result of the pandemic and massive workload in hospitals. Another development that we at Airlec have noticed is that it has become quite difficult to secure beds – especially intensive care unit (ICU) beds – all over France. Whilst the situation is not as bad as it is currently in the UK, we do feel the effect of an overloaded healthcare system.”
Heywood told ITIJ that remnants of the old French colonies also mean that international repatriations are relatively common: “Residents in overseas French territories, such as the West Indies, are routinely transported to mainland France for treatment not available locally. As a result, commercial airlines such as Air France/KLM offer stretchers onboard as a routine procedure and there are several very experienced private air ambulance companies.”
France has been one of the world’s leading tourist destinations for more than 30 years. In 2019 (the last year for ‘normal’ figures), 90 million international tourists visited France; in the same year tourism accounted for eight per cent of gross domestic product.
In June 2021, French Prime Minister Jean Castex presented the goals set out in the Destination France plan. This plan aims to set a trajectory of 10 years for the tourism sector to bounce back after being hit particularly hard by the public health crisis.
the main nationalities of the tourists the company is currently assisting are from Western Europe, but that he is gradually seeing more visitors coming from the US, Middle East and Asia
Data from the United Nations World Tourism Organisation (UNWTO) shows that France saw a 45-per-cent decline in tourist expenditure in 2020 compared to 2019, and then a 31-per-cent decrease in 2021 compared to 2019, so it’s fair to say that the recovery is underway. Strict travel restrictions throughout 2021 no doubt contributed to this slower recovery. France’s leading source market of tourists has long been the UK, and complex rules for travel from the UK to France – who remembers the ill-thought-through ‘red, amber, amber-plus, and green’ list of travel restrictions? – meant that many travellers who would normally have headed across the Channel chose alternative destinations in 2021.
De Badaoui told ITIJ that the main nationalities of the tourists the company is currently assisting are from Western Europe, but that he is gradually seeing more visitors coming from the US, Middle East and Asia. He added: “The number of tourists is not a problem, but it’s a matter of being able to match international tourists’ requirements; an assistance company will be able to support [them], but the patient might often end up disappointed not having the service he is expecting. For example, you will find tens of providers of teleconsultation, appointments booked online in French with no real support, no cashless service, service not being available every day, however very few are offering the expected service: to be available 365 days a year, offering bilingual support with a human touch beyond a teleconsultation. The same applies for outpatient appointments, inpatient medical monitoring, ground ambulance arrangement, medical escorts and all medical services related to the assistance field.”
IPMI and international student health insurance
Of course, it’s not just leisure visitors heading back out into the big wide world again post-Covid. International study abroad programmes are also recommencing, and France is a popular destination for these young travellers. Insurance provider APRIL International has reported ‘a substantial increase’ in the number of policy enquiries it is seeing for this niche group of clients. Isabelle Moins, Head of the International Private Medical Insurance (IPMI) Division for Europe at APRIL International, told ITIJ: “In many ways, volumes are above forecast, as there is both the normal intake and the backlog.”
APRIL’s clients are granted a free medical phone consultation system
Travellers and students in their early 20s are at particularly high risk of needing mental health support services while they are away from their home country, and specific services need to be in place to ensure these needs are being met. Telemedicine services are going to be an essential tool in the box for insurers with these clients – younger clients will appreciate the immediate solutions on offer. APRIL’s clients are granted a free medical phone consultation system, offering unlimited 24/7 support. “Importantly, TeleHEALTH includes expert mental health support,” Moins added.
IPMI is also a must-have for expats in France, and those numbers are also increasing once again, according to APRIL, despite new Brexit rules on residency. A visa is required for all stays of over three months, but this will not be issued without evidence of private health insurance, such as short-term IPMI cover. Moins told ITIJ: “Once fully registered with a visa, expats will have access to the basic free state healthcare on offer, so the demand is likely to be for bespoke top-up cover.”
Challenges remain, but the outlook for travel insurers is positive
According to Global Data, net earned travel insurance premiums in France are going to rise from a forecast of US$2.86 billion in 2022 to $3.37 billion in 2026, which shows slow but steady increases in the coming few years.
Manogna Vangari, Insurance Analyst at GlobalData, comments: “Travel insurance demand in France is poised for a steady recovery with further easing in travel restrictions and insurers making provisions related to Covid-19 in travel policies. The growth is expected to be around 2.6 per cent in 2022 and have a value €2.4 billion ($3 billion) in terms of net earned premium.
The travel insurance loss ratio is expected to consistently improve from an estimated 70.5 per cent in 2022 to 68.2 per cent in 2025
With living and travelling with Covid-19 becoming the new normal, many French insurers have introduced varied provisions on its inclusion in travel insurance, ranging from healthcare and quarantine costs, trip cancellation or modification, and refunds due to delays in test results. The focus is also on policy wordings to ensure the fulfillment of specified conditions to qualify for benefits.
Ms.Vangari adds: “We expect that with these added measures, technical results of travel insurance will somewhat improve until 2025. The travel insurance loss ratio is expected to consistently improve from an estimated 70.5 per cent in 2022 to 68.2 per cent in 2025. Diversification of distribution channels, including sales through wholesale brokers via their booking platforms, start-ups, travel blogs, and online aggregators, will further aid growth in travel insurance. Between 2022 and 2025, travel insurance is expected to grow at an average annual growth of 3.3 per cent.”
ITIJ spoke to Allianz’s travel team in France about how they view the country’s travel insurance market at the moment, and generally, it seems to be a positive outlook. “We are observing an increase in the insurance conversion rate by almost 40 per cent compared to 2019,” said Catherine Dibouès, Regional Head of Product Management & Innovation Travel, at Allianz Travel. This was attributed to a couple of reasons:
- The increase in destinations that have made travel insurance mandatory for entry into their territory from Covid
- Travellers have become more sensitive to risks and therefore more willing to purchase travel insurance.
“However,” she continued, “it should be noted that this increase in the conversion rate would never have been possible if we had not adapted our offers to the needs of travellers – from 2020, we were among the first insurers to offer coverage for epidemics/pandemics including those related to Covid-19.”
France – plenty to offer for insurers and quality healthcare system
Paul Tiba of Airlec extolled the virtues of France as a destination in which insurers can be confident that the needs of their insureds will be catered to: “France – the country where medical assistance and aeromedical repatriations were invented – has a deeply rooted assistance mindset in its medical healthcare system and regional medical operations. French doctors truly live the spirit of assistance, which is well supported and acknowledged by the French government, which often works closely with assistance and aeromedical companies when French citizens need help abroad. Due to the amazing diplomatic network and understanding that France is a safe haven with excellent medical practices it allows for the most complex missions to be planned and performed.”