The Haut Comité pour l'Avenir de l'Assurance Maladie (HCAAM), created in 2003 and now composed of more than 70 representatives of all stakeholders in the healthcare system, has published - without a vote or proposal - its feasibility study report on four polar scenarios for the evolution of the articulation between compulsory (RO) and complementary (OCAM) health insurance schemes. This report is the culmination of a reflection initiated in 2018 and led by its general secretariat; note that it benefited from the support of an inter-administrative working group for the drafting. It is nevertheless very surprising that the 4 scenarios proposed - or rather 4 variations of the same scenario - are "one way", that of a complete state financing of health expenditure.
No reflection on a form of cooperation
Two points are striking on reading the report. Firstly, it is a text "against" complementary health insurance organizations and the compulsory system is adorned with all the virtues. Secondly, it is a "rear-view mirror" vision and there is a total absence of consideration of the dynamics (technological, organizational, etc.) underway and of changes in the needs of the population and in healthcare spending. While the hospital must make the "ambulatory turn" and work more and more with the city, and while the city medicine must deploy new models of organization that are much more collaborative between doctors and paramedics, the HCAAM's general secretariat does not envisage any reflection on the articulation between compulsory and complementary schemes in the form of cooperation.
Statization is a dead end
Contrary to what the HCAAM report presupposes, the co-piloting of the health system by the Ministry of Health and the national health insurance fund is leading to a dead end. It is responsible for the illegibility of the reimbursement grids, for the level of tariffs that encourage professionals to focus on volume and the performance of simple procedures, and for the slow deployment of alternative models to fee-for-service payment...
Current events illustrate this impasse. While the Covid crisis is deteriorating the mental health of the population, especially of children and adolescents - to the point that Santé Publique France has reinforced its surveillance system - the future coverage of psychologists' consultations by the compulsory health insurance scheme is doomed to failure (mainly because of a much too low reimbursement base and an inadequate link with general medicine). Why has the compulsory health insurance scheme not worked with the OCAMs, which had nevertheless taken the initiative in 2021 to fully cover 4 psychologist sessions, from which more than one million people have already benefited?
The status quo is no longer possible
Taking into account the challenges of the health system as a whole gives a completely different perspective, which is out of all proportion to the €7.9 billion cost of managing the OCAMs that mobilize the HCAAM. These issues are well known. We will retain several things: First, catching up in mental health, which is the leading item of expenditure for health insurance by disease, then adapting the supply of care to the epidemiological transition (chronic diseases are now the leading cause of mortality and account for more than 65% of expenditure). A national policy of primary and secondary prevention must also be implemented, with the aim of combating avoidable mortality, which is one of the highest in France among European countries.
Finally, we must fight against social and territorial inequalities in health, which are constantly increasing.
How can an even tighter framework for the supplementary scheme, or even its disappearance, enable the compulsory scheme to better address these issues, which it has been struggling to do alone for decades?
Mobilize complementary health insurance organizations
The OCAMs are the primary financiers of optical, dental and audio prosthetic expenses. Today, in the dental field for example, the compulsory scheme pilots the "M'tes dents" program for children and adolescents, but without any coordination with the OCAMs. The participation rate, while improving, remains far from the objectives and social inequalities remain very high.
In these areas, where they make a major contribution to the solvency of expenditure, mobilizing the OCAMs on public health objectives would be a strong lever for improving the quality and relevance of care. These objectives would be those of a risk management policy applicable to all players.
The OCAMs finance nearly half of the city care expenses of the socially insured (85% of the population). As such, they could also contribute as investors to the reorganization of primary care services: organization of graded care paths according to needs, inclusion of psychologists, linkage with hospitals for real follow-up of hospitalizations or even alternatives to hospitalization, development of telemedicine, etc. Legal vehicles to encourage and support these investments already exist: trusts, cooperative health companies, etc.
Although the compulsory health insurance scheme bears the major part of the cost of long-term illnesses, the technical costs of these patients are on average twice as high for the OCAMs as for other insured persons. There are two main reasons for this: these patients are more fragile and suffer more from other pathologies than other ALDs, and many expenses related to their ALD(s) are not covered or are very poorly covered by the RO (extra fees, private rooms in hospitals, consumables, etc.). However, the burden of long-term illnesses, which already account for 65% of health insurance expenditure, will increase in the coming decades due to the ageing of the population and the lack of an active primary prevention policy (at least 40% of these illnesses could be avoided through changes in behaviour). Here again, there are many areas of articulation between RO and OCAM to be explored: secondary prevention, patient support programs, etc.
These issues go far beyond the €7.9 billion in OCAM management costs that have mobilized the HCAAM over the past four years! If the cohabitation of the two compulsory and complementary schemes does not bring enough value today and generates too high management costs, it is certainly not by suppressing the smaller of the two that the larger will be more efficient. On the contrary, it is by forcing the two schemes to organize their complementarity and to coordinate. When will the HCAAM undertake this work?
Olivier Milcamps (Senior Manager)