Economics serving society

Does the level of health cover influence medical practices?

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Carine Milcent*

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The system of access to health care in France is one of the most particular and complex systems in the world. The reimbursement of expenditure on a given medical service links together a social security system based on deductions that are made independent of the state of health, risk factors and co-morbidities of the individual involved and a complementary insurance system based on the state of health of its subscribers. At the end of 2021, the High Council for the Future of Health Insurance (HCAAM) was asked by the health minister to study the ways in which the system could be made more equally accessible while also making it more transparent. The HCAAM’s report highlights the prices differences in complementary insurance premiums for a very similar coverage. The differences are linked to the employment status of the person covered: employees, independents, the unemployed, and the retired. Users make economic choices when buying different levels of coverage. Leaving aside the 5% of French who have no complementary health insurance, the different kinds of behaviour in relation to health care can be separated according to the supplementary insurance contracts taken out and the package of care that is covered by them.

Using hospital data, Carine Milcent and Saad Zbiri study the question of the effect of complementary cover on medical practices. As an example, they take the case of maternity care. A woman can have her baby in a public hospital or in a private clinic. The hospital costs of the birth are entirely covered by the state medical insurance. However, additional charges imposed by private institutions are not covered by state insurance. Depending on the level of complementary insurance coverage, these additional costs are partially or fully reimbursed.

The choice of care during childbirth is expressed differently depending on the health facility. In public hospitals, the woman is monitored by a medical team. These institutions are overloaded. There is no direct financial interest in favouring a natural birth over a caesarean section birth but planning and team management are facilitated by a planned caesarean. The midwife who monitors the delivery involves an obstetrician only when there are complications that require a caesarean operation. In the private clinics, the woman has a discretionary relationship with her obstetrician, part of whose fee is conditional on being present during the birth. Practitioners have direct incentives for the type of delivery, which are both financial and managerial.

Milcent and Zbiri present part of their analysis of the group of women who present no complications during pregnancy, have no need for a caesarean section, and have brought their pregnancy to term, in order to isolate the cases where the medical practice of a planned caesarean is not directly dictated by medical considerations. First, it seems that the percentage of caesareans is higher in private clinics than in public hospitals. Then, distinguishing between women on the basis of whether their complementary insurance covers the extra fees involved in such an operation, the results vary. Women admitted into clinics whose complementary insurance does not cover the extra fees have a significantly lower probability of undergoing a caesarean operation.

This finding demonstrates the importance of greater equality of access to care regardless of the socio-economic situation of patients. It also warns of the necessity for a reconsideration of what should be covered by the public health insurance, in order to promote collectively adequate medical practices.

Original title of the article: “Supplementary private health insurance: the impact of physician financial incentives on medical practice”
Published in : Health Economics, 2021:1-6
Available at :DOI :

*PSE Researcher

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