Showing posts with label europe. Show all posts
Showing posts with label europe. Show all posts
Friday, March 28, 2008
Becoming a resident of France?
Legal Living in France
By Melissa Schulz
It took me six months to figure out the appropriate steps to take to live in France legally. The options are: finding a French employer who will arrange a visa, marrying a French citizen, joining the Foreign Legion, or becoming a student. The last option seemed to be the easiest and less emotionally exhausting.
All you have to do is sign up at one of the French for foreigners schools in Paris recognized by the French government (below), present your registration card at the French consulate in your home state, and get your student visa. All the schools offer programs to suit your level and needs, and some offer aid with the paperwork and housing. Request catalogues from each school and review them carefully before making a decision. (The Sorbonne is the most popular and least personal; it is also least expensive.)
After deciding on the school, you can register by phone, email, or fax. If you are in France, go directly to the school and preregister, then obtain your visa back in America. You must sign up for at least 20 hours of French a week to apply for a visa. Sign up for one year if you want a long-term student visa. Depending upon the school, you may have the option of making payments instead of paying all fees at once.
The next step is to go to the French consulate in your state of residence with all the necessary papers. The documents you will need vary from state to state, so check your local consulate web site.
Once in France, the first thing you need to do is get your Carte de Sejour at the police prefecture. Take with you to the prefecture: your final registration at the school of your choice (which you receive after taking your placement test), proof of payment of tuition, and proof of health insurance. If you are over 28, you have to get private coverage, which you can buy in France or America. Look in Fusac, www.fusac.fr a journal for English-speaking residents in France, and carefully compare prices. Take your insurance ID card, proof of residence, and proof of financial support to your local prefecture. The required documents vary, so ask your school to help you with the process. If you have the option, bring a French person with you.
Once you have your Carte de Sejour and you are legal you can open a bank account, get a mobile phone, and find part-time employment more easily. Try to start the process at least two months in advance of your departure. The peace of mind is worth the pain.
French Schools for Foreigners
Institut Catholique de Paris, 12 Rue Cassette, 75006 Paris; 011-33-01-44-39-52-68, fax 011-33-01-44-39-52-09; ilcf@icp.fr, www.icp.fr.
La Sorbonne, 47 rue des Ecoles, 75005 Paris; 011-33-01-40-46-22-11, fax 011-33-01-40-46-32-29; ccfs@paris4.sorbonne.fr, www.fle.fr/sorbonne. Cost per semester (20 hours a week for 12 weeks):
Alliance Francaise, 101 Blvd. Raspail, 75270 Paris; 011-01-42-84-90-00; info@alliancefr.org, www.alliancefr.org.
Basic residency rules for France
ALTHOUGH Johnny Halliday may have fled to Switzerland to dodge the French tax authorities, it is not an option open to many.
So issues concerning tax are likely to be high up on many people’s agendas when they are thinking about a move to France.
And the biggest factor that will decide how the tax office will treat you will be where you are considered resident.
An individual, whether a French or foreign national, is resident according to the French tax code if:
- You have a permanent home or principal place of sejour in France.
- You spend more than 183 days in France during a calendar year or spend more time in France that any other country.
- You carry out an occupation or are employed in France, except where this is incidental to a foreign activity.
- Your centre of economic interest is in France.
So if you fall into one of these brackets you are considered French resident and will pay taxes on your worldwide income.
But if you are outside, then you are considered non-resident and would pay taxes only on your French source income.
The tax authorities will decide your status at first and you are allowed to appeal if you do not agree with their decision.
But it can be seen that the rules have nothing to do with visas, passports, property ownership – you could be renting and be considered French resident for tax purposes.
If you have decided to move to France permanently then you should contact the tax authorities in your current country.
They may ask you to provide evidence that you are no longer resident, for example, in the UK the Inland Revenue ask if you have taken steps to acquire accommodation abroad.
It is possible that you may receive a tax refund but also you affairs will be tied off, ready to be set-up abroad.
However, it could occur that you fall between two stools and this is where the double taxation treaty between the UK and France comes in.
France also has taxation treaties with all other EU states as well as the USA, Australia, Canada and around 70 other countries.
But what the agreements ensure is that income that has already been taxed in one country is not liable to tax in another.
For example, pensions received from the UK, except for government pensions, will be taxed in France and not in the UK.
Residency and double taxation treaties are complex affairs and professional advice should be sought – but it is an important consideration.
A useful starting point is the Inland Revenue website:
Residents and non-residents - Liability to tax in the United Kingdom or Tax when living abroad.
By Craig McGinty on January 31, 2007, admin. In Property | Site RSS feed | Free newsletter
E-mail to a friend | Add to del.icio.us | Digg this | StumbleUpon | Listen to article
More: « Paris to adopt bike scheme | Home | Holiday home website tips »
Comments
Thanks so much for this post, I've been wondering about this since I moved here about a yr ago! The tax issue had to be resolved eventually & I'm glad to have found out certain things from your post.
Posted by: shannon | 7 Feb 2007 21:44:20
Hi Shannon, glad the article has helped out - at least getting your tax straight is one less worry.
All the best, Craig
Posted by: Craig McGinty | 8 Feb 2007 21:31:34
Canadian Resident dies and he has his RRIF benificiary his sister in UK. What are the taxes of the RRIF and who has to pay for it. Is it the estate or the benificiary. What are the witholding taxes in Canada. In the treaty it says that we can keep up to 43% witholding taxes in Canada and send the rest to UK. Nobody seems to know the right answer. We have been in touch with Ernest & Yound the biggest accounting firm in Vancouver and they don't have a clue about it. We have 3 lawyers working on this case and we don't have any definite answer. We are sure that this has happened before and how the accountants and the lawyers have delt with it. Please help, we are frustrated and don't know whom else to speak to. The Revenue Canada tells us that we have to hold the taxes in Canada but the accountants and the lawyers are doubtful about it.
Posted by: Heidi Baloun | 9 Mar 2007 21:20:27
I wonder if anyone can help me find out some information on becoming a french resident.
I am 2 years off retirement age, own a building project in france and work as a carer in England. I work for an agency so I pay my own tax, in other words I'm self employed. I would like to become a french resident this year and comute from time to time to carry on the work I'm doing in England.
Questions I'm looking for answeres to are:-
If I declare my earnings in france for tax purposes, would I have to pay social charges.-Equivelent to Nat. Ins. contributions? and is this alot mor than I pay in England?
Also would I be entitled to an E106?
Sophia
Posted by: Sophia Lee | 16 Jan 2008 15:48:52
Hi Sophia
If you are considered French resident then you would be included in their taxation system, so would be asked to pay social charges.
Contributions are higher than the UK, although the overall tax take is not that different, and I'm sure people would say that the services you receive are much better.
As for the E106 that only applies to people not working who would be entitled to Incapacity Benefit, and is for a limited period, more here:
http://www.dwp.gov.uk/international/sa29/medical_06.asp
So if you were paying into the system as self-employed then you would receive health cover as normal, and upon retirement receive cover as if you were in the UK.
I'd take a look over the Department of Work and Pensions website and give them a call.
Hope this helps
Craig
By Melissa Schulz
It took me six months to figure out the appropriate steps to take to live in France legally. The options are: finding a French employer who will arrange a visa, marrying a French citizen, joining the Foreign Legion, or becoming a student. The last option seemed to be the easiest and less emotionally exhausting.
All you have to do is sign up at one of the French for foreigners schools in Paris recognized by the French government (below), present your registration card at the French consulate in your home state, and get your student visa. All the schools offer programs to suit your level and needs, and some offer aid with the paperwork and housing. Request catalogues from each school and review them carefully before making a decision. (The Sorbonne is the most popular and least personal; it is also least expensive.)
After deciding on the school, you can register by phone, email, or fax. If you are in France, go directly to the school and preregister, then obtain your visa back in America. You must sign up for at least 20 hours of French a week to apply for a visa. Sign up for one year if you want a long-term student visa. Depending upon the school, you may have the option of making payments instead of paying all fees at once.
The next step is to go to the French consulate in your state of residence with all the necessary papers. The documents you will need vary from state to state, so check your local consulate web site.
Once in France, the first thing you need to do is get your Carte de Sejour at the police prefecture. Take with you to the prefecture: your final registration at the school of your choice (which you receive after taking your placement test), proof of payment of tuition, and proof of health insurance. If you are over 28, you have to get private coverage, which you can buy in France or America. Look in Fusac, www.fusac.fr a journal for English-speaking residents in France, and carefully compare prices. Take your insurance ID card, proof of residence, and proof of financial support to your local prefecture. The required documents vary, so ask your school to help you with the process. If you have the option, bring a French person with you.
Once you have your Carte de Sejour and you are legal you can open a bank account, get a mobile phone, and find part-time employment more easily. Try to start the process at least two months in advance of your departure. The peace of mind is worth the pain.
French Schools for Foreigners
Institut Catholique de Paris, 12 Rue Cassette, 75006 Paris; 011-33-01-44-39-52-68, fax 011-33-01-44-39-52-09; ilcf@icp.fr, www.icp.fr.
La Sorbonne, 47 rue des Ecoles, 75005 Paris; 011-33-01-40-46-22-11, fax 011-33-01-40-46-32-29; ccfs@paris4.sorbonne.fr, www.fle.fr/sorbonne. Cost per semester (20 hours a week for 12 weeks):
Alliance Francaise, 101 Blvd. Raspail, 75270 Paris; 011-01-42-84-90-00; info@alliancefr.org, www.alliancefr.org.
Basic residency rules for France
ALTHOUGH Johnny Halliday may have fled to Switzerland to dodge the French tax authorities, it is not an option open to many.
So issues concerning tax are likely to be high up on many people’s agendas when they are thinking about a move to France.
And the biggest factor that will decide how the tax office will treat you will be where you are considered resident.
An individual, whether a French or foreign national, is resident according to the French tax code if:
- You have a permanent home or principal place of sejour in France.
- You spend more than 183 days in France during a calendar year or spend more time in France that any other country.
- You carry out an occupation or are employed in France, except where this is incidental to a foreign activity.
- Your centre of economic interest is in France.
So if you fall into one of these brackets you are considered French resident and will pay taxes on your worldwide income.
But if you are outside, then you are considered non-resident and would pay taxes only on your French source income.
The tax authorities will decide your status at first and you are allowed to appeal if you do not agree with their decision.
But it can be seen that the rules have nothing to do with visas, passports, property ownership – you could be renting and be considered French resident for tax purposes.
If you have decided to move to France permanently then you should contact the tax authorities in your current country.
They may ask you to provide evidence that you are no longer resident, for example, in the UK the Inland Revenue ask if you have taken steps to acquire accommodation abroad.
It is possible that you may receive a tax refund but also you affairs will be tied off, ready to be set-up abroad.
However, it could occur that you fall between two stools and this is where the double taxation treaty between the UK and France comes in.
France also has taxation treaties with all other EU states as well as the USA, Australia, Canada and around 70 other countries.
But what the agreements ensure is that income that has already been taxed in one country is not liable to tax in another.
For example, pensions received from the UK, except for government pensions, will be taxed in France and not in the UK.
Residency and double taxation treaties are complex affairs and professional advice should be sought – but it is an important consideration.
A useful starting point is the Inland Revenue website:
Residents and non-residents - Liability to tax in the United Kingdom or Tax when living abroad.
By Craig McGinty on January 31, 2007, admin. In Property | Site RSS feed | Free newsletter
E-mail to a friend | Add to del.icio.us | Digg this | StumbleUpon | Listen to article
More: « Paris to adopt bike scheme | Home | Holiday home website tips »
Comments
Thanks so much for this post, I've been wondering about this since I moved here about a yr ago! The tax issue had to be resolved eventually & I'm glad to have found out certain things from your post.
Posted by: shannon | 7 Feb 2007 21:44:20
Hi Shannon, glad the article has helped out - at least getting your tax straight is one less worry.
All the best, Craig
Posted by: Craig McGinty | 8 Feb 2007 21:31:34
Canadian Resident dies and he has his RRIF benificiary his sister in UK. What are the taxes of the RRIF and who has to pay for it. Is it the estate or the benificiary. What are the witholding taxes in Canada. In the treaty it says that we can keep up to 43% witholding taxes in Canada and send the rest to UK. Nobody seems to know the right answer. We have been in touch with Ernest & Yound the biggest accounting firm in Vancouver and they don't have a clue about it. We have 3 lawyers working on this case and we don't have any definite answer. We are sure that this has happened before and how the accountants and the lawyers have delt with it. Please help, we are frustrated and don't know whom else to speak to. The Revenue Canada tells us that we have to hold the taxes in Canada but the accountants and the lawyers are doubtful about it.
Posted by: Heidi Baloun | 9 Mar 2007 21:20:27
I wonder if anyone can help me find out some information on becoming a french resident.
I am 2 years off retirement age, own a building project in france and work as a carer in England. I work for an agency so I pay my own tax, in other words I'm self employed. I would like to become a french resident this year and comute from time to time to carry on the work I'm doing in England.
Questions I'm looking for answeres to are:-
If I declare my earnings in france for tax purposes, would I have to pay social charges.-Equivelent to Nat. Ins. contributions? and is this alot mor than I pay in England?
Also would I be entitled to an E106?
Sophia
Posted by: Sophia Lee | 16 Jan 2008 15:48:52
Hi Sophia
If you are considered French resident then you would be included in their taxation system, so would be asked to pay social charges.
Contributions are higher than the UK, although the overall tax take is not that different, and I'm sure people would say that the services you receive are much better.
As for the E106 that only applies to people not working who would be entitled to Incapacity Benefit, and is for a limited period, more here:
http://www.dwp.gov.uk/international/sa29/medical_06.asp
So if you were paying into the system as self-employed then you would receive health cover as normal, and upon retirement receive cover as if you were in the UK.
I'd take a look over the Department of Work and Pensions website and give them a call.
Hope this helps
Craig
The French Health Care System
Doctors still make house calls? Click here
The French Health Care System
Article Date: 27 Jun 2004 - 15:00 PST
-- HEALTH INSURANCE AND ACCESS TO CARE --
To best understand how the French health care system works, I think it is best to begin with a look at the French health insurance system.
First of all, all legal residents of France are covered by public health insurance, which is one of the social security system's entitlement programs. The public health insurance program was set up in 1945 and coverage was gradually expanded over the years to all legal residents: indeed, until January 2000, a small part of the population was still denied access to the public health insurance.
The funding and benefits of the French public health insurance system (PHIS), much like Germany's, were originally based on professional activity. The main fund covers 80% of the population. Two other funds cover the self-employed and agricultural workers.
Once varying depending on the fund, disparate reimbursement rates were replaced by uniform rates. The funds are financed by employer and employee contributions, as well as personal income taxes. The latter's share of the financing has been ever-increasing in order to:
� compensate for the relative decrease of wage income,
� limit price distortions on the labor market,
� and more fairly distribute the system's financing among citizens.
Most health insurance funds are private entities which are jointly managed by employers' federations and union federations, under the State's supervision. The joint labor/management handling has always sown discord within the funds' boards, as well as between the boards and the State.
As a consequence, the responsibilities of the various actors in the system are not always shared in the most coherent manner.
For example, the parliament's budget provisions determine how much public money will go to health expenditure, the cabinet decides reimbursement rates and sets the amount of contributions earmarked for the funds, while the funds themselves negotiate with health care professions to set tariffs designed to ensure the system operates at the breakeven point. Responsibilities are frequently redefined, but never to satisfaction of all involved.
1 Permanent Working Group of European Junior Doctors, October 2001.
2 1 rue Paul C�zanne 75008 Paris France. couffinhal@irdes.fr, www..fr, Tel: 33(0)153934318.
The views expressed here are those of the author, and they do not necessarily reflect the views of the IRDES.
Agn�s Couffinhal - IRDES October 2001 2
The public health insurance system covers about 75% of total health expenditures. Half of the outstanding amount is covered by patients' out-of-pocket payments and the other half is paid by private health insurance companies. These supplementary health insurance policies can be taken out by individuals or groups.
About 85% of the population own such policies.
An important peculiarity of the French PHIS is that the funds cover a very wide range of goods and services, including for example, stays in thermal spas.
In the hope of curbing consumption and expenditures, copayments were implemented and have increased over time. These copayments are relatively high for many out-patient services.
For example, patients must pay 30% of Social security's tariff for a physician's visit, moreover, roughly 40% of specialists and 15% of GPs are allowed to charge more than the tariff. Copayments are also high for dental prostheses and eye-ware. This tended to deter the poorest citizens (few of whom had supplementary insurance) from seeking care. Concerns grew over the system's inequity.
In January 2000, a means-tested, public supplementary insurance program called CMU (Couverture maladie universelle) was implemented to ensure the poor access to health care.
For those whose income is below a certain threshold (about 10% of the population is eligible), this insurance covers all public copayments and offers lumps-sum reimbursements for glasses and dental prostheses. Health professionals are not allowed to charge more than the public tariff or the lump-sum for CMU beneficiaries, which means that in theory, access to care is free of charge.
In passing, I'd like to mention that many experts advocate a change in the way health insurance covers care. They think it would be more efficient and equitable to clearly define a set of indispensable goods and services which should be available to everyone and which should be 100% publicly financed. The remaining goods and services would be available to those who desire and can afford them, with or without relying on private insurance.
To close this aside on access to care, I'd like to add that, as far as I know, France is the only country in which access to care is unlimited: patients can see as many physicians as often as they like. Patients do not need referrals to see specialists, and in general, there is no gatekeeping system of any kind. This may partially account for the World Health Organization's high ranking of France's health care system last year: the rating system emphasized the system's responsiveness (a measure of patients' freedom and flexibility), a quality the French system provides, undeniably at the expense of overall efficiency.
Agn�s Couffinhal - IRDES October 2001 3
-- THE STATE'S ROLE --
1. The State decides on what care is to be reimbursed and to what extent, defines the responsibilities of the various actors, and ensures that the entire population has access to care.
2. The State defends patients' rights, drafting and enforcing relevant policy. The State is thus responsible for safety within the health system. The disaster and subsequent cover-up of the contamination of the nation's hemoglobin supply with HIV-tainted blood resulted in the revamping of public health policy. New agencies were created to oversee safety measures concerning the nation's blood supply, organ donor programs, food, and medical goods and services. The recent handling of the mad cow crisis indicates that these changes have improved public safety.
3. The State is also in charge of planning. Health authorities decide on the size and number of hospitals, as well as the amount and allocation of highly technical equipment (MRI, CTscans...). It organizes the supply of specialized wards (transplants, neurosurgery...) and ensures the provision of care at all times, like emergency rooms.
Since 1991, some of the planning has taken place at the regional level. Indeed, more and more policy-making and negotiation are undertaken at the regional level, and this tendency is likely to continue in the coming years.
-- THE CARE SUPPLY HOSPITALS --
In France, hospitals have always been the core of the health care system. This probably accounts for the extremely specialized, technical, curative nature of our care, arguably to the detriment of prevention and community services.
The number of hospital beds has decreased over time: it currently stands at 8.4 per 1,000 inhabitants, which is close to the European average. Hospitals can be roughly divided into two categories: public, and private for-profit.
� The public sector represents about 65% of the beds. Public hospitals have specific obligations such as ensuring the continuity of care, teaching, and training. They receive a budget which is largely based on a historical basis.
� Private for-profit hospitals concentrate on surgical procedures and rely mostly on fee-forservice remuneration for their funding.
A uniform hospital information system has been implemented to monitor the various establishments activity. Gradually, all public and private establishments are to switch to DRG payment systems.
Agn�s Couffinhal - IRDES October 2001 4
-- HEALTH PROFESSIONALS --
Of the many types of health professionals, I would like to focus on physicians, as they play a key political role in the system. There are currently about 200,800 physicians licensed to practice in France. In the last thirty years the number of physicians has tripled, but the rate of increase is now very slight. Indeed, since 1971, the Ministry of Health has limited the number of medical students, a measure which, along with the retirement of currently active doctors, will result in a decrease in the number of physicians in the near future.
Half of the physicians are specialists.
In France, physicians (and other professionals) generally work in two kinds of environments: public hospitals and private practices. 25% of physicians work in public hospitals (another 11% work in other types of public establishments). They are in essence public servants and paid an amount that is fixed by the government. Today, many physicians feel that the prestige of working in a hospital does not compensate for the trying working conditions. 56% of physicians work in private practices3, and are paid on a fee-for-service basis.
The relative weight of the procedures is set by experts and the prices are negotiated by physicians' unions and public health insurance funds4.
Since the creation of Social Security, the relationship between private practice physicians and the State and public insurance funds has always been strained. A contract (convention) which sets the general regulatory framework and the remuneration of the profession is supposed to be signed every 5 years by physicians unions. The first one was signed in 1971, 26 years after public health insurance was created. Subsequent conventions allowed some physicians to charge more than social security tariffs (1980), limited this right (1990) and implemented official medical practice guidelines (RMO, R�f�rences m�dicales opposables) in 1993.
The current situation is particularly strained: negotiations between doctors' unions and the funds have stalled, leaving the specialists without a convention and isolating the GP union which signed a convention in 1998. The root of the problem is that private practice physicians are strongly opposed to the setting caps on outpatient expenditures. They have always had a great deal of freedom over where they set up shop, how they practice, and what they prescribe (compared to their counterparts in other countries). Yet the bulk of their income is paid by public funds. This contradiction has become more glaring as the concerns about soaring health expenditures grew.
The French Health Care System
Article Date: 27 Jun 2004 - 15:00 PST
-- HEALTH INSURANCE AND ACCESS TO CARE --
To best understand how the French health care system works, I think it is best to begin with a look at the French health insurance system.
First of all, all legal residents of France are covered by public health insurance, which is one of the social security system's entitlement programs. The public health insurance program was set up in 1945 and coverage was gradually expanded over the years to all legal residents: indeed, until January 2000, a small part of the population was still denied access to the public health insurance.
The funding and benefits of the French public health insurance system (PHIS), much like Germany's, were originally based on professional activity. The main fund covers 80% of the population. Two other funds cover the self-employed and agricultural workers.
Once varying depending on the fund, disparate reimbursement rates were replaced by uniform rates. The funds are financed by employer and employee contributions, as well as personal income taxes. The latter's share of the financing has been ever-increasing in order to:
� compensate for the relative decrease of wage income,
� limit price distortions on the labor market,
� and more fairly distribute the system's financing among citizens.
Most health insurance funds are private entities which are jointly managed by employers' federations and union federations, under the State's supervision. The joint labor/management handling has always sown discord within the funds' boards, as well as between the boards and the State.
As a consequence, the responsibilities of the various actors in the system are not always shared in the most coherent manner.
For example, the parliament's budget provisions determine how much public money will go to health expenditure, the cabinet decides reimbursement rates and sets the amount of contributions earmarked for the funds, while the funds themselves negotiate with health care professions to set tariffs designed to ensure the system operates at the breakeven point. Responsibilities are frequently redefined, but never to satisfaction of all involved.
1 Permanent Working Group of European Junior Doctors, October 2001.
2 1 rue Paul C�zanne 75008 Paris France. couffinhal@irdes.fr, www..fr, Tel: 33(0)153934318.
The views expressed here are those of the author, and they do not necessarily reflect the views of the IRDES.
Agn�s Couffinhal - IRDES October 2001 2
The public health insurance system covers about 75% of total health expenditures. Half of the outstanding amount is covered by patients' out-of-pocket payments and the other half is paid by private health insurance companies. These supplementary health insurance policies can be taken out by individuals or groups.
About 85% of the population own such policies.
An important peculiarity of the French PHIS is that the funds cover a very wide range of goods and services, including for example, stays in thermal spas.
In the hope of curbing consumption and expenditures, copayments were implemented and have increased over time. These copayments are relatively high for many out-patient services.
For example, patients must pay 30% of Social security's tariff for a physician's visit, moreover, roughly 40% of specialists and 15% of GPs are allowed to charge more than the tariff. Copayments are also high for dental prostheses and eye-ware. This tended to deter the poorest citizens (few of whom had supplementary insurance) from seeking care. Concerns grew over the system's inequity.
In January 2000, a means-tested, public supplementary insurance program called CMU (Couverture maladie universelle) was implemented to ensure the poor access to health care.
For those whose income is below a certain threshold (about 10% of the population is eligible), this insurance covers all public copayments and offers lumps-sum reimbursements for glasses and dental prostheses. Health professionals are not allowed to charge more than the public tariff or the lump-sum for CMU beneficiaries, which means that in theory, access to care is free of charge.
In passing, I'd like to mention that many experts advocate a change in the way health insurance covers care. They think it would be more efficient and equitable to clearly define a set of indispensable goods and services which should be available to everyone and which should be 100% publicly financed. The remaining goods and services would be available to those who desire and can afford them, with or without relying on private insurance.
To close this aside on access to care, I'd like to add that, as far as I know, France is the only country in which access to care is unlimited: patients can see as many physicians as often as they like. Patients do not need referrals to see specialists, and in general, there is no gatekeeping system of any kind. This may partially account for the World Health Organization's high ranking of France's health care system last year: the rating system emphasized the system's responsiveness (a measure of patients' freedom and flexibility), a quality the French system provides, undeniably at the expense of overall efficiency.
Agn�s Couffinhal - IRDES October 2001 3
-- THE STATE'S ROLE --
1. The State decides on what care is to be reimbursed and to what extent, defines the responsibilities of the various actors, and ensures that the entire population has access to care.
2. The State defends patients' rights, drafting and enforcing relevant policy. The State is thus responsible for safety within the health system. The disaster and subsequent cover-up of the contamination of the nation's hemoglobin supply with HIV-tainted blood resulted in the revamping of public health policy. New agencies were created to oversee safety measures concerning the nation's blood supply, organ donor programs, food, and medical goods and services. The recent handling of the mad cow crisis indicates that these changes have improved public safety.
3. The State is also in charge of planning. Health authorities decide on the size and number of hospitals, as well as the amount and allocation of highly technical equipment (MRI, CTscans...). It organizes the supply of specialized wards (transplants, neurosurgery...) and ensures the provision of care at all times, like emergency rooms.
Since 1991, some of the planning has taken place at the regional level. Indeed, more and more policy-making and negotiation are undertaken at the regional level, and this tendency is likely to continue in the coming years.
-- THE CARE SUPPLY HOSPITALS --
In France, hospitals have always been the core of the health care system. This probably accounts for the extremely specialized, technical, curative nature of our care, arguably to the detriment of prevention and community services.
The number of hospital beds has decreased over time: it currently stands at 8.4 per 1,000 inhabitants, which is close to the European average. Hospitals can be roughly divided into two categories: public, and private for-profit.
� The public sector represents about 65% of the beds. Public hospitals have specific obligations such as ensuring the continuity of care, teaching, and training. They receive a budget which is largely based on a historical basis.
� Private for-profit hospitals concentrate on surgical procedures and rely mostly on fee-forservice remuneration for their funding.
A uniform hospital information system has been implemented to monitor the various establishments activity. Gradually, all public and private establishments are to switch to DRG payment systems.
Agn�s Couffinhal - IRDES October 2001 4
-- HEALTH PROFESSIONALS --
Of the many types of health professionals, I would like to focus on physicians, as they play a key political role in the system. There are currently about 200,800 physicians licensed to practice in France. In the last thirty years the number of physicians has tripled, but the rate of increase is now very slight. Indeed, since 1971, the Ministry of Health has limited the number of medical students, a measure which, along with the retirement of currently active doctors, will result in a decrease in the number of physicians in the near future.
Half of the physicians are specialists.
In France, physicians (and other professionals) generally work in two kinds of environments: public hospitals and private practices. 25% of physicians work in public hospitals (another 11% work in other types of public establishments). They are in essence public servants and paid an amount that is fixed by the government. Today, many physicians feel that the prestige of working in a hospital does not compensate for the trying working conditions. 56% of physicians work in private practices3, and are paid on a fee-for-service basis.
The relative weight of the procedures is set by experts and the prices are negotiated by physicians' unions and public health insurance funds4.
Since the creation of Social Security, the relationship between private practice physicians and the State and public insurance funds has always been strained. A contract (convention) which sets the general regulatory framework and the remuneration of the profession is supposed to be signed every 5 years by physicians unions. The first one was signed in 1971, 26 years after public health insurance was created. Subsequent conventions allowed some physicians to charge more than social security tariffs (1980), limited this right (1990) and implemented official medical practice guidelines (RMO, R�f�rences m�dicales opposables) in 1993.
The current situation is particularly strained: negotiations between doctors' unions and the funds have stalled, leaving the specialists without a convention and isolating the GP union which signed a convention in 1998. The root of the problem is that private practice physicians are strongly opposed to the setting caps on outpatient expenditures. They have always had a great deal of freedom over where they set up shop, how they practice, and what they prescribe (compared to their counterparts in other countries). Yet the bulk of their income is paid by public funds. This contradiction has become more glaring as the concerns about soaring health expenditures grew.
Subscribe to:
Comments (Atom)