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Relationships between CMU players - P4H Network

Changing relationships between players in the Couverture Maladie Universelle system

1945/46 | Setting up of departmental conventions

Relations between doctors, who are the main authorizers of healthcare and health insurance expenditure, and the health insurance scheme are designed to be governed by agreements negotiated at departmental level and approved in equal parts by representatives of doctors, the health insurance scheme and the State.

If negotiations fail, the government is supposed to set up an authoritative tariff. Failing this, the direct agreement between the practitioner and the local health insurance fund to which he is attached prevails.


Free pricing is the subject of a lively debate between doctors and public authorities that began at the end of the 19th century, following the first law on free medical assistance passed in 1893. Doctors organized early on: their first union, whose motto was “For a liberal and social medicine”, was created in 1928. It acts to defend their interests in the face of plans to regulate their fees, making fee-for-service payment and direct agreement with the patient’s health insurance fund major principles, as are free choice of doctor, professional secrecy and freedom of prescription.

The 1945/46 system was slowly put in place until the mid-50s, after many ups and downs, with doctors opposing the signing of a number of departmental agreements for varying lengths of time or for good.

Even though doctors were still represented by just one union, the history of their relationship with health insurance was a tumultuous one. In addition to the fundamental issue of contractualization, the main recurring topics of debate are the level of fees, their possible differentiation and capping, their uniformity across the country, the possibility of and limits on fee overruns, the level of social benefits enjoyed by the patrician, and whether or not to introduce third-party payment for the benefit of the insured.

For the insured, the fundamental issue is to ensure consistency between the rates charged by doctors and the rates reimbursed by the health insurance scheme, so that his or her contribution to healthcare expenditure (the “reste à charge”) is acceptable and limited.

1960 | Setting up a standard departmental medical agreement

That year saw the introduction of a standard departmental medical agreement, most of whose clauses are binding. Negotiations are above all bipartite, between the doctors’ union and the health insurance company, with the government overseeing and approving tariffs.


The French government is in a position to set enforceable tariffs in departments where negotiations between the health insurance scheme and the medical union have failed.

The substantial increase in tariffs helped to set up the new system, and then the series of conflictual events resumed. By the end of the 60s, it was becoming increasingly difficult for the union to function, especially after the emergence in early 1968 of a second union which was in fierce rivalry with its competitor.

1971 | Creation of national health insurance agreements

National health insurance agreements have been set up with practitioners and medical auxiliaries, the main authorizers of healthcare and health insurance expenditure. The 1st four-year national agreement with doctors was signed in October of the same year.


In the autumn of 1968, the “historic” union took industrial action and, for the first time, decided to raise fees unilaterally, causing a stir among policyholders. He obtained partial satisfaction. State, health insurance and doctors’ unions realized the need for a thorough review of conventional relations.

From 1971 onwards, relations between the health professions and the health insurance system, which until then had been governed by the local health insurance funds, became a national affair between the most representative unions in the profession concerned and the national health insurance fund of the Régime général. The national funds of the other two major schemes may enter into joint agreements with the latter.

The 1st national agreement sets fixed prices for all doctors, with the exception of certain well-known doctors who have a permanent right to exceed their prices. Some doctors may choose to opt out of the agreement, in which case policyholders are reimbursed on the basis of much lower official rates. The national fund can place practitioners who fail to meet their commitments outside the agreement.

Implementing the 1st national convention is very complicated. Tough tariff negotiations then set the pace for the four-yearly renewal of the agreement.

1971 | Introduction of " numerus clausus "

From now on, the numérus clausus will regulate the number of medical and dental students admitted to universities.


The scheme is intended as a tool for regulating the number of healthcare professionals, given the strong appetite of young people for these professions. It will soon be extended to other healthcare professions (pharmacists, midwives, etc.). It will be the subject of recurring discussions and disputes.

1975 | Recognition of the administered price of drugs and medical devices

While pricing is becoming totally free within the economy, the prices of drugs and medical devices remain administered.


The specificity of the drugs and medical devices sector, as falling within the scope of coverage by Social Security and complementary health insurance, has been recognized. Free pricing in this sector would clearly stand in the way of such care under good conditions for policyholders.

Generally speaking, public authorities must ensure that administered tariffs are coherent and compatible with health insurance reimbursement tariffs.

1979 | Creation of the Commission des comptes de la sécurité sociale.

The Commission des Comptes de la Sécurité Sociale is created and placed under the authority of a Secretary General who is an active member of the Cour des Comptes.


The creation of the Commission des Comptes de la Sécurité Sociale (Social Security Accounts Commission) has made it possible to gradually introduce a high degree of transparency into the figures and mechanisms of the Social Security system, and first and foremost, but not exclusively, health insurance.
Because of the way they are produced, these very rich data are not contested. The commission’s substantial reports, published twice a year, introduce elements of trust into relations between the players in the healthcare and health insurance systems.

1980 | Creation of a new national agreement for free-tariff doctors (" sector 2 ")

A new national agreement for doctors has created a free-tariff sector, known as sector 2 (sector 1 being the sector where conventional tariffs apply), and incorporates a concerted cost-control mechanism known as the “global envelope”.


The practice of medical and paramedical professionals charging fees in excess of those set by the health insurance scheme has been around since 1946. Attempts to regulate them have consistently failed. The creation of a free-rate sector (sector 2) finally recognized the phenomenon, but failed to regulate it completely.

Practitioners can choose – initially once a year, then every two years – whether to opt for sector 2, i.e. free pricing. In this way, they waive their health insurance contributions, and their procedures will be reimbursed within the limits set for doctors who respect the tariffs.

Each year, health insurance funds and doctors must set targets to limit growth in expenditure to the level of revenue. Practitioners who go over the limit may be penalized by a braking of conventional tariffs when they come up for review twice a year.

The new medical agreement therefore includes a concerted cost-containment mechanism, the “global envelope”, which is intended to provide a framework for conventional negotiations.

1983 | Introduction of the global endowment for health establishments

The global grant is introduced as a method of financing public health establishments and private establishments participating in the public hospital service.


Until now, hospitals were paid according to the number and length of inpatient stays. As hospital expenditure is not subject to a ceiling, this method of financing, which is considered to be increasingly inflationary, has led to a substantial reform, differentiating the methods of financing healthcare establishments according to their legal status.

Public health establishments and private establishments participating in the public hospital service now have an annual operating budget – known as a global allocation. It is calculated on the basis of the number of days and renewed each year on the basis of the previous year, modulated by a guideline rate for growth in hospital expenditure. Very little of the budget is subject to negotiation between the supervisory authority and the establishment.

Private, for-profit healthcare establishments bill the health insurance scheme directly for fixed-rate services (remuneration of the facility) and procedures (remuneration of independent healthcare professionals), on the basis of geographically variable rates negotiated with the regional health and social action directorates (DRASS) and, since 1996, with the regional hospitalization agencies (ARH). These establishments therefore benefit from activity-based payments, based on variable regional tariffs. Since 1991, service packages have been governed by national quantified objectives (OQN) designed to regulate funding in relation to activity.

1990 | "Freeze" in Sector 2

In order to guarantee the level of reimbursement of healthcare costs for policyholders, the new medical agreement provides for a “freeze” on sector 2.


Following an acute conflict between the public authorities and doctors’ unions, the new agreement, signed with difficulty by a single union, stipulates that doctors who had already joined sector 2 will continue to benefit from tariff freedom, and that only former clinical directors and hospital assistants will be able to opt for sector 2 when they first set up practice. This compromise will enable a gradual reduction in excess fees for general practitioners, who will no longer be able to join sector 2. It offers no such guarantees for specialist doctors.

1991 | First global framework for controlling healthcare expenditure

A tripartite contractual mechanism – involving the State, health insurance funds and representatives of the healthcare professions – sets quantified national expenditure targets (OQN), together with an adjustment mechanism to ensure they are met.


As far as the liberal healthcare professions are concerned, the quantified national expenditure targets, as part of the framework for their contractual negotiations, are rather indicative in scope. For doctors, the OQN replaces the “global envelope” created in their national agreement with the health insurance scheme in 1980.
On the other hand, from 1991 onwards, private hospitals’ service packages have been governed by OQNs, which aim to regulate their financing in relation to their activity.

1991 | Introduction of regional organization plans

The Schémas régionaux d’organisation sanitaire (SROS – regional health organization plans) ensure the distribution of public and private facilities and activities. Multi-year contracts between establishments, health insurance funds, representatives of the State and local authorities are signed to ensure that the objectives of these regional plans are achieved.


The Schémas régionaux d’organisation sanitaire (regional health organization plans) aim to rationalize hospital care provision on the basis of the health map. They develop contractual links between players in the healthcare system.

1996 | Creation of the annual Social Security Financing Acts and the National Health Insurance Expenditure Target

In 1996, the annual Social Security Financing Acts (LFSS) were created, and within them the National Health Insurance Expenditure Target (ONDAM), which replaces the OQN.


This major reform, which required an amendment to the Constitution, aims to create a debate in Parliament every autumn on social security policy, given the importance of social security (in particular, its expenditure exceeds that of the State budget). There are now two financial bills for the following year debated in Parliament: the Finance Bill (State budget) and the Social Security Finance Bill (PLFSS).

The 1996 system will be reviewed and strengthened in 2005 and again in 2021, in particular to increase the multi-year dimension of the law, broaden and clarify its content, and enhance the wealth of information provided by its appendices.

The LFSS determine the conditions for the financial equilibrium of Social Security. They define revenue forecasts, set expenditure targets for each branch, including the health branch, establish a balance forecast, and contain new revenue and expenditure measures. They make decisions for the current year (corrective measures) and for the coming year. They draw up forecasts of income, expenditure and balances for the following three years.

A key element of this law is the National Health Insurance Expenditure Target (ONDAM), which is broken down into sub-targets. As its name suggests, this is legally a standard for expenditure trends, not a restrictive budget envelope. Politically, the challenge is to set the ONDAM at a level that is reasonable in terms of healthcare needs, but sustainable in terms of revenue forecasts, and to stick to it.

After a long period of low credibility, when it was systematically exceeded, the ONDAM was respected every year from 2010 to 2019, and even under-executed. It has been at the heart of the recurring debate on the degree of medicalization that should be involved in controlling health insurance expenditure.

In 2020 and 2021, the COVID 19 health crisis and its consequences for the healthcare system and health insurance turned the data upside down. The ONDAM has been destabilized and significantly exceeded. The health crisis has revealed its structural weaknesses.
After years of pay restraint that led to increasing dysfunction in our establishments, brought to light by the health crisis, the pay rises decided as part of the consultation process with healthcare system stakeholders known as the “Ségur de la santé” (May/July 2020) have partly enabled us to catch up in this area.

In 2021, the Haut conseil pour l’assurance maladie (High Council for Health Insurance) put forward proposals on healthcare regulation, in particular to rebuild the ONDAM tool. The major challenge is to give new credibility to this tool.

1996 | Creation of Regional Hospitalization Agencies (ARH) and multi-year contracts for objectives and resources

Regional Hospitalization Agencies (ARH) are decentralized government bodies. Multi-year contracts for objectives and resources (CPOM) are signed by ARH with healthcare establishments.


A decentralized government agency, the ARH is responsible for the regional management of healthcare establishments (planning and resource allocation). They defined and implemented regional policy, as close as possible to the needs of the population.

In the past, health issues were dealt with by the Regional Health and Social Affairs Departments (DRASS). Given the importance and specific nature of healthcare establishments, it was decided to set up a specialized organization and give it new means of action, including CPOMs. ARH was replaced by ARS in 2010.

1999 | Compulsory tariffs for care covered by complementary universal health insurance

The law instituting universal health coverage (CMU) obliges sector 2 doctors to comply with mandatory fees for care provided to beneficiaries of complementary universal health coverage (CMUC).


This measure potentially concerned more than 5 million people. Some sector 2 doctors were in no hurry to treat those concerned.

1999 | Experimentation with pathology-based financing of healthcare establishments

As of January 1, 2000, a 5-year trial of new financing methods for public and private healthcare establishments has been launched, based on pathology-based pricing.


The major disparity in funding introduced in 1983 between public health establishments and private establishments participating in the public hospital service, on the one hand, and private not-for-profit establishments, on the other, made it complex to control funding and difficult to compare costs between the two sectors. The aim of the trial was to verify the relevance of a new system designed to cover all healthcare establishments.

2004 | Introduction of a "ticket modérateur" and a "parcours avec médecin " traitant "". Creation of the health insurance card (carte Vitale), " contrats responsables " and shared medical records

A fixed contribution payable by the insured is introduced, which cannot be covered by complementary health insurance (ticket modérateur d’ordre public).

The health care pathway is now organized around the “attending” doctor, who must be chosen by the insured person, failing which health insurance reimbursements will be reduced.

The health insurance card (carte Vitale) is created, a personal, secure smart card issued to each insured person, but not to their beneficiaries. It contains all the administrative information needed to manage your care.

Responsible contracts” bind complementary health insurance providers and policyholders. These contracts are not intended to cover expenses incurred as a result of non-compliance with the healthcare pathway.

Finally, the shared medical record (DMP) has been created.


All these measures contained in a health insurance law were implemented within a reasonable timeframe.
The same cannot be said of the DMP, whose concept definition and tool construction have been highly complicated, and whose deployment is still not complete.

2004 | Creation of the French Health Authority

Haute autorité en santé (HAS), an independent public scientific authority. With a wide range of assessment, recommendation, measurement and improvement missions, it aims to develop quality in the health, social and medico-social fields, for the benefit of individuals.


For the most part, the HAS brings together missions already carried out by existing institutions or commissions, streamlining and revitalizing them, and deploying new ones.

With its governance structured around an eight-member College, including a President, and specialized commissions, it has three fundamental missions:

  • Evaluate the medical service rendered by drugs, medical devices and professional procedures with a view to reimbursement;
  • Recommend best professional practices, draw up vaccination and public health recommendations;
  • Measuring and improving quality in hospitals, clinics, outpatient clinics, social and medico-social structures.

It works alongside public authorities, helping them to make informed decisions, with professionals to optimize their practices and organizations, and for the benefit of users, empowering them to make their own choices. The COVID 19 health crisis placed a heavy demand on its vaccine recommendation function.

2004 | Introduction of activity-based pricing (T2A)

Activity-based pricing becomes the virtually unique method of financing medical, surgical, obstetric and dental activities in all public and private healthcare establishments. It is based on a logic of measuring the nature and volume of activities, rather than on a system of expenditure authorizations.


T2A is based on the measurement and evaluation of the actual activity of establishments, which determines the resources allocated to them.

It replaced a dual financing system that distinguished between public establishments and private establishments participating in the public hospital service (which received a lump-sum global financing allocation unrelated to changes in activity) and private establishments (financed according to a system that took activity into account, but on the basis of variable regional tariffs).

Certain activities that are difficult for patients to identify, known as missions of general interest and contractual aid, are not included in this scheme (notably teaching, research, reference and innovation missions; emergency services; coordination of organ harvesting and transplants; prevention and screening actions; vigilance and epidemiology actions, health monitoring). Certain high-cost drugs and medical devices are reimbursed in addition to service charges.

A ramp-up mechanism for the reform has been designed differently for the public and private sectors, to take into account the specific management rules of each sector and enable them to adapt to the new system as smoothly as possible. For the public sector, the ramp-up was spread over the period 2004-2008.

The T2A system has subsequently evolved to adjust the model even more closely to facilities’ activities and missions.

2010 | Replacement of ARH by Regional Health Agencies

The Agence régionale de santé (ARS) replaces the Agences régionales de l’hospitalisation (ARH).


While confirming ARH’s role in defining and implementing regional healthcare policy, and in steering the healthcare system at regional level (planning and resource allocation), the reform has extended the scope of the organizations’ activities to include health crisis management, the medico-social sector, outpatient medicine and preventive actions.

In view of this new scope of action, some of the administrative and medical departments of the French health insurance system have been transferred to form the departments of the new agencies.

2011 | Introduction of remuneration based on public health objectives for private practitioners

The new medical agreement for remuneration based on public health objectives (ROSP) has been created for private practitioners.


The creation of the ROSP marks a turning point in the remuneration of these doctors: in addition to fee-for-service remuneration, it introduces an element of performance-based payment. Its aim is to help medical practices evolve to meet the health objectives defined in the agreement.

The indicators on which ROPS is calculated have been reviewed several times as part of the renewal of our agreements.

2017 | Reform of the third-party payment mechanism

The “tiers payant” mechanism enables healthcare professionals to waive the advance payment of healthcare costs to their patients. A 2015 law had provided for an extension of the third-party payment mechanism to all insured persons applying compulsorily to healthcare professionals. This generalization, not yet implemented, was abandoned in 2017, in favor of targeted advances in the obligation attached to this mechanism. Third-party payment is said to be full if the treatment is covered by Social Security. Otherwise, it is said to be partial: the insured pays the costs or the part of the costs not covered by the health insurance scheme or by his or her supplementary health insurance, if he or she has one.


In 2022, third-party payment will be compulsory for care covered for maternity, an accident at work or an occupational disease, or for a long-term illness (ALD). It is also compulsory for policyholders hospitalized in an establishment under agreement with the French health insurance scheme, for the implementation of the 100% health scheme (audiology, optics and dentistry), for victims of acts of terrorism, and for beneficiaries of the complementary health insurance scheme (CSS) or the Aide médicale de l’État (AME). It is also compulsory for preventive procedures as part of organized screening, for voluntary termination of pregnancy (IVG) and, in the case of under-26s, for contraception consultations.

Third-party payment is authorized in all other cases, but remains an option for healthcare professionals, not an obligation.

2019 - New reform for mixed financing of healthcare facilities

The aim of this reform is to achieve a 50% financing rate based on activity (T2A) and to combine five different financing methods.


A report on reforming the financing of the healthcare system submitted to the government in early 2019 considers that activity-based pricing does not promote quality of care or prevention, and may even encourage the provision of irrelevant care. In its proposal for a new financing model, T2A does not disappear, but is combined with other flat-rate remuneration methods, notably for the management of chronic diseases and the elderly. This system aims to take better account of patient follow-up, prevention and care coordination activities. The financing of hospital care should be modulated according to relevance (verification of the relevance of medical procedures) and quality (a financial allocation based on quality indicators).

T2A has in fact focused on the productivity and profitability of healthcare activities, without taking sufficient account of demographic and disease trends, or of the links between hospital and community care.

The report’s proposals feed into the implementation of the “Ma Santé 2022” plan embodied in the July 24, 2019 law on the organization and transformation of the healthcare system. The aim is to achieve 50% T2A financing and combine five different financing methods:

  • payment for patient monitoring, particularly for chronic diseases (diabetes, kidney disease, etc.);
  • payment for quality and relevance ;
  • payment for service restructuring, including adaptation to the psychiatric sector(new window) ;
  • bundled payment per care sequence to encourage cooperation between care providers ;
  • a share of fee-for-service and stay-based payment adapted to single episodes of care.

Pending the gradual implementation of this reform, an emergency plan for hospitals provides for additional funding for healthcare establishments over three years in November 2019, with a corresponding increase in the National Health Insurance Expenditure Target (ONDAM), as well as the assumption by the Caisse d’amortissement de la dette sociale of one-third of the debt of public healthcare establishments and private establishments participating in the public hospital service.

At the beginning of 2023, it became clear that this reform was not working. A new reform is scheduled for 2023.

2021 | Abolition of numerus clausus

The numerus clausus limiting the number of health students, primarily medical students, accepted by universities and other training organizations has been abolished.


To combat the shortage of private and hospital doctors, the numerus clausus limiting the number of students admitted to the second year of medical, midwifery, dental or pharmacy studies has been replaced by a numerus apertus since the start of the academic year in autumn 2021, meaning that it can be increased.

This measure will not solve the problems of medical demography, which include the decline in the number of general practitioners in favor of specialists, the insufficient number of specialists in several specialties, and the increasingly unbalanced distribution of doctors across the country (“medical deserts”).

This last subject is at the heart of the negotiations opened at the end of 2022 and which will continue into 2023 for the renewal of the agreement between the unions of self-employed doctors and the health insurance scheme. One of the main topics under discussion is the evolution of the tariff for doctors’ consultations (the tariff for a general practitioner’s consultation is currently 25 euros). One of the challenges in setting these rates is to ensure that the cost is covered by the health insurance system and the insured’s supplementary health insurance, so that the latter’s contribution (the “reste à charge”) is low.