Explains the ways in which oral healthcare is provided and financed in France.
Highlights the absence of a dental public health structure.
Identifies the current challenges to the system of reducing costs and moving towards a more preventive healthcare model.
The French oral health system is based on the provision of dental treatment and is organised around a fee-per-item model. The system is funded by a complex mix of public and complementary health insurance schemes. The system is successful in that it provides access to affordable dental treatment to the majority of the French population. However, France had the highest health expenditure as a share of gross domestic product (GDP) of all European Union countries in 2008 and rising oral health inequalities may be exacerbated by the manner in which oral health care is provided and funded. In addition, there is no organised national strategy for the prevention of oral diseases or for oral health promotion.
The impact of European legislation enabling freedom of movement of professionals within the European Economic Area (EEA) has led to increasing mobility of dental professionals between member states. By the end of 2014, it was estimated that 17% of all dentists on the UK Dentists Register, including 86 from France, graduated from EEA dental schools outside of the UK.1 Of all dentists registering for the first time in France in 2014, 32.5% graduated from a non-French EEA dental school (477 professionals).2 Over the last 15 years, there have been increasing calls for harmonisation of dental education and of the roles given to both dental specialists and other dental care professionals, such as hygienists. This objective has been hindered by fundamental political differences in the way that health care and education have been traditionally organised in the different member states.
This article will describe the oral healthcare system in France, a country with a population of 66 million in 2013 and the third largest total gross national product in Europe, behind Germany and the UK.
The French healthcare system
The French Sécurité Sociale was created in 1945 to provide state financial protection against lifetime risks for the population. It includes public health insurance, compensation for accidents at work and occupational diseases, pensions and family benefits. The principles of universality and unity form the basis of the system, which was established on the Bismarck model of social contributions related to work. Originally, the system only provided health insurance for the worker, his or her spouse and their children. Increasing levels of unemployment led to the creation of universal health coverage (CMU) in 1999. All legal French residents are now entitled to public health insurance and the system is no longer funded solely from social contributions related to work but also by taxes. The government has responsibility for the financial and operational management of health insurance by setting premium levels related to income and by determining the prices of goods and services refunded. A national body (Caisse Nationale) negotiates with the medical trade unions to establish a list of treatment items and medication eligible for reimbursement. A national fixed fee is applicable for each of these items, corresponding to the maximum level of reimbursement insured by the public health insurance scheme. Every year parliament votes a national target for public health insurance expenditure although this budget is only indicative. The vast majority of medical professionals draw the best part of their income from the public insurance funds.
The French healthcare system is thus based on a fee-per-item scale. In most cases, public health insurance covers 70% of the fixed fee for items of treatment, except for patients with a recognised chronic condition who are reimbursed 100% of the fixed fee.3 In many circumstances the professional, even under contract with the state, is freely allowed to charge a tariff over and above the fixed fee. This system currently applies to consultations with 10% of general practitioners and 65% of specialists. In addition, hospitals or clinics charge a 'day-pass' fee, which is not covered by the public health insurance system.
It is thus important for most people to have a complementary health insurance policy, although this is not compulsory. There are many organisations offering complementary health insurance schemes (685 in 2010).4 Contracts can be individual or collective. Collective contracts are offered by companies to their employees and are either obligatory or optional. In 2011, collective contracts represented 42% of contracts and 85% of these were obligatory. Virtually all contracts pay the percentage charge not reimbursed by the public health insurance system, when the national fixed fee is not exceeded, and the 'day-pass' hospital fee. However, contracts differ greatly in their level of payment of fees over and above the fixed fee, in particular for dental care, glasses or hearing aids.
The government introduced a complementary public health insurance scheme in 1999 to improve access to care for the more vulnerable members of the population (CMUc: Couverture Maladie Universelle Complémentaire). To benefit from this extended coverage, the patient has to have an annual income lower than a fixed ceiling of resources, taking into account the size of the family. For a single person, the cut-off was €720 per calendar month in 2014.5 The CMUc provides 100% cover of fixed fees and the hospital 'day-pass' from the public purse. Professionals are not allowed to charge over and above the fixed rate of consultation for these patients and there is specific provision for dental treatment and glasses. In addition, low-income earners, who are not eligible for CMUc coverage, but whose income is less than 35% above the CMUc ceiling (€973 pcm for a single person), benefit from financial support towards the cost of a complementary health insurance scheme (ACS: Aide à la Complémentaire Santé). Finally, there is another public plan (AME: Aide Médicale d'Etat) for illegal immigrants that have been resident in France for at least three months. By law, professionals cannot refuse to treat patients that benefit from the CMUc or the AME.
Patients are able to register with the general medical practitioner of their choice. Patients may also freely choose to consult a specialist but the rate of reimbursement by the public health insurance scheme is reduced if the patient is not referred to the specialist by their general practitioner. However, there is no regulation for either general or specialist dentistry.
In terms of financial outlay for the patient, until recently the patient paid the full fee on contact with the professional and was subsequently reimbursed. Increasingly, the public health insurance system now pays its share directly to the professional and the patient only pays the remainder (termed third-party payment). Certain complementary health insurance companies are now also setting up this system to reduce the time that the patient is out of pocket. Those that benefit from the CMUc or the AME receive care that is free at source, the system paying 100% of the fixed fee directly to the professional.
Costs and financing
In 2013, total health expenditure as measured by the French authorities was €247.7 billion (11.7% of GDP). When the cost of long-term care for the elderly and people with disability is excluded, the expenditure was €186.7 billion or €2,843 per inhabitant (8.8% of GDP).6 This expenditure was funded by the public health insurance system (76%), the state and CMUc (1.4%), complementary health insurance schemes (13.8%), and households (8.8%). The cost of the AME, which is paid by the state, was €712 million. In 2013, only €5.8 billion was assigned to prevention in general healthcare.
In 2014, the public health insurance system was funded by social contributions (46.5%), by taxation (47.3%) and from various other sources (6.2%).7 The public health insurance scheme has long been in deficit and in 2014 the deficit amounted to €6,521 billion. The social debt, concerning the whole of the Sécurité Sociale, was €162 billion at the end of 2013.
Dental treatment: public and complementary health insurance
Items of dental treatment are covered in three different ways by the public health insurance system:
The first group includes items which are fully regulated. The public health insurance system reimburses 70% of their fixed cost. This group includes examination and basic treatment (examination, extractions, restorative dentistry, endodontic treatment, scaling, radiography and fissure sealing)
The second group includes items which are partially regulated. There is a fixed fee but the practitioner is allowed to charge more. This is true for most treatment requiring laboratory work (crowns, bridges, removable dentures etc), and orthodontic treatment (if started before the age of 16)
All other treatments are non-regulated and thus not reimbursed by the public health insurance system (periodontal treatment, implants, conscious sedation etc).
The CMUc covers 100% of fees for fully regulated items. For partially regulated items under this scheme, the practitioner is obliged to apply the fixed fees. The professional receives the full fixed fee directly from the public health insurance system and treatment for the patient is free at source.
For partially regulated items, the cover of the complementary health insurance schemes is usually defined as a percentage of the fixed fee, ranging from 30% to over 600%, or sometimes as a maximum annual sum of cover. Over the years, some complementary health insurances have started to cover non-regulated items, such as implants. To illustrate the different types of funding,3,8 see Tables 1, 2, 3 and 4.
In addition, there is a national 'preventive' plan called 'M'T dents' which concerns all children and teenagers aged 6, 9, 12, 15 or 18 years. Children can benefit from a preventive examination and subsequent basic treatment which are covered 100% by the public health insurance system. Recently the plan has been extended to pregnant women between the fourth month of pregnancy and the twelfth day after delivery. In the original programme, one-hour long health prevention sessions were to be scheduled for all primary school children but this part of the project has now been dropped.
Oral healthcare costs and financing
In 2013, oral healthcare expenditure was €10,637 billion, 5.7% of healthcare expenditure.6 The distribution of funding of oral healthcare was: public health insurance 32.1%; CMUc 3.3%; complementary health insurance 39.3%; and households 25.3%. It is difficult, however, to collect accurate figures because data are only available for regulated items. This implies that the cost of care paid directly by householders is highly underestimated. The proportion of overall expenditure related to charges over and above the fixed fee has continued to increase over time, in line with overall increase in expenditure. This proportion for general dental practitioners exceeded 50% in 2009 and reached 53.2% in 2013. Over this period, the fixed fees for regulated items have not been re-evaluated.9 There is broad consensus that fixed fee items are undervalued (see Tables 1, 2, 3, 4). The funding of oral health prevention and promotion is derisory. Therefore, dental practices only start to make profit when undertaking partially regulated or non-regulated items of treatment.
Oral healthcare workforce
To practice dentistry, a practitioner must be a citizen of a European Economic Area (EEA) country, have a diploma from an EEA dental school and be registered at the 'Ordre des Chirurgiens-dentistes' (OCD), the national professional board managing the registration of dentists in France. The OCD guarantees compliance with the principles of morality, integrity, competency and dedication necessary for the practice of dentistry, and compliance by all members to professional obligations and rules laid down in a code of conduct.
In France in 2014, 41,495 dentists were in active practice of whom less than 6% were specialists (up to 2014, the only speciality was orthodontics). More than 85% of dentists were independent practitioners. The average age was 48 years. Female dentists made up 42%, with a higher proportion of female dentists under 30 years (50%). In 2014, the mean density was 62.9 dentists/100,000 inhabitants with wide geographical disparity; from 33 in the north to 112 in the south of France. Within regions, there were also wide disparities between rural and urban sectors.10 In some areas that have difficulty attracting young practitioners, the situation is worsening as the practising professionals are ageing – in the 'Centre' region 43% of dentists are over 55 years of age. Recently graduated dentists tend to stay in the region where they graduated with 71% to 97% staying around university cities.
Approximately 4% of dentists currently working in France graduated abroad but things are changing rapidly. In 2014, 1,466 practitioners registered for the first time and among these 34.7% graduated outside of France, compared to 27% in 2013. These dentists are mostly Romanian (40%), Spanish (20%), Portuguese (16%) or French having studied abroad (16%). This new phenomenon will impact on the demographic situation.2 The dentists who graduated abroad tend to stay in attractive urban areas with 31% of them working in the Paris region.2
Salaried dentists are rare, most being attached to hospitals and dental faculties. A minority of dentists are employed by municipal clinics, public health insurance schemes or by the armed forces. Outside the dental schools, no dentist is employed in a dental public health role, and only very few work (usually part time) in prevention, screening or oral health promotion for local authorities. There is no French Chief Dental Officer and no community dental service.
The density of dentists is a particularly important indicator of dental services in France, as neither dental hygienists nor dental therapists exist. The only recognised auxiliary personnel are dental chair side assistants, receptionists and dental technicians. Employment law in France is prohibitive and nearly half of dentists work without full-time chair-side support from a dental assistant.11 Dental assistants do not have a national diploma and dental nursing is not recognised as a health profession.11 The vast majority of dental technicians work within private laboratories. They are not permitted to treat patients. For financial reasons, some dentists work with laboratories outside of France (for example, in Morocco, South Korea or India).
Independent dental practitioners are obliged to subscribe to a national pension scheme that relies on the immediate contributions of active practitioners to pay pensions owed to retirees (that is, a pay-as-you-go pension scheme that does not use a capital investment fund to ensure future pension rights). This system is a source of tension as the number of dentists entering training is fixed at a national and at a regional level. Between 1970 and 1990 this number was lowered, leading to an unfavourable ratio of active to retired dentists. The number of dentists allowed into training has been gradually increased from 800 in 2001 to 1,200 in 2013, in order to ensure the replacement of the high number of dentists who graduated between 1968 and 1985.10 It has been suggested that by increasing the number of young dentists, geographical disparities in services might also be reduced.
Dental education is provided within 16 publicly funded dental schools, which are mixed university and hospital structures. Students pay university enrolment fees (€200 to €400 per year)12 and 13 out of the 16 dental schools require the student to pay for their dental equipment (at a cost varying between €330 and €3,400 in 2014).13 Students are salaried by the hospital during their clinical years (receiving €228.40 per month for a sixth year student in 201014). In total, 1,200 new second year students entered the French dental schools in 2013. The first year in the dental curriculum is common to medicine, dentistry, midwifery and pharmacy, and includes basic sciences, medical sciences, and human and social science. In addition, the student can opt for modules that are specific to their chosen discipline. At the end of this year, a competitive examination allows access to the different disciplines. The duration of the dental curriculum is six years and culminates in the public presentation of a 'thesis' and a period of internship in general dental practice. The curriculum has been modified recently in order to fit the European structure of health studies. At the end of the fifth year, some students choose to sit a competitive examination that allows access to specialist training with a full time internship of three to four years in a university hospital. Since 2011, there are three recognised specialities: orthodontics, oral surgery and 'medicine bucco-dentaire' (aimed at gaining advanced skills either for hospital practice, for the management of specific populations, or for a university career in an academic clinical discipline). In 2015–2016, for new entrants to specialist education, 53 training posts will be available for orthodontics, 42 for advanced/hospital dentistry and 15 for oral surgery. Specialist trainees are paid a hospital salary of €16,506–25,348 pa before tax, depending on year of study.15
Continuing professional education was made mandatory in 2004. The law states that continuing professional education should aim for the 'evaluation of professional practices, development of knowledge, improvement of quality and safety of care, recognition of public health priorities and medical control of health spending'. However, only 18% of dentists were registered with the state agency governing continuing education in 2013.16 Dental schools also offer university diplomas or certificates for postgraduates, although these do not give access to specialist qualifications. The only measure of quality control within dental practice is regulation by the public health insurance system regarding reimbursement of regulated items of treatment.
Prevention and oral health promotion
The French oral health system is based on the provision of dental treatment. There is no organised national strategy for the prevention of oral diseases or for oral health promotion. Oral diseases are considered independently, without integration into overall health or into other health promotion programmes.
Fluoridated toothpastes are readily available in France (<1,500 ppm). Fluoridated salt has been available in France since 1987 (250 mg/kg) but the public is very badly informed about this measure.17 The sale of fluoridated salt has progressively decreased since 1987 to less than 8% of the total sales of table salt in 200718 and the decline in caries observed in children and adolescents between 1987 and 2006 cannot be attributed to the implementation of salt fluoridation.19,20 Fluoride supplements are sold on prescription in pharmacies, with guidelines limiting their use to children with a high caries risk.21 The rate of utilisation of fluoride supplements is low and decreases with increased age.17 On average, French people use 2.4 toothbrushes and 4.4 tubes of toothpaste per year and per person, which is considered insufficient.22 Toothpaste and toothbrushes are currently subject to 20% VAT, while fizzy drinks are taxed at 5.5%. People with high levels of oral disease particularly need support in adopting healthy behaviours through the promotion of supportive life environments. Various non-governmental, non-profit organisations, such as the ASPBD (Société Française des Acteurs en Santé Publique Bucco-Dentaire) or the UFSBD (Union Francaise pour la Santé Bucco Dentaire) are doing their best to promote oral health and to conduct preventive and oral health education interventions. Dental schools, local administrations or health funds are also helping in this field. These programmes are not organised at a national or a regional level and are frequently short term. Many children have never participated in an oral health education or preventive programme. Evaluation of the impact of those interventions on dental status and oral health behaviour is very rare.23,24,25,26,27
The departmental health services for maternal and childhood protection are encouraged to include oral health in their medical consultations in kindergartens but only 5 out of 95 services have an active dental programme. The Regional Health Agencies are public structures in charge of supporting regional health projects adapted to local needs in the fields of health promotion, prevention, healthcare or social support. They can finance regional health promotion projects conducted by local communities or associations. The only national preventive measure is 'M'T dents', described above.28
In France, there is no regular monitoring of the dental status of the child population. The last national study was conducted in 2006; the mean DMFT was 1.23 at 12 years with 56% of children caries free.20 France was thus considered to be in a middle situation in Europe between Northern countries (DMFT <1) and Eastern countries (DMFT >3).29 Concerning the oral health of younger children, little regional data is available. In the Lorraine Region in 2002, 37% of 4-year-old children presented with caries and 6.2% had received dental treatment.30 In deprived schools in Clermont-Ferrand in 2003, 5-year-old children had a mean dmft of 1.18 with 28% having at least one tooth affected.31 Caries prevalence was 33% in a recent survey of a sample of 6-year-old children in the south of France.32
Very few national epidemiological studies have been conducted on the oral health of the adult population over the last 20 years.33,34 In 2003, a national survey of periodontal disease evaluated 2,132 subjects aged 35 to 64 years. Approximately 80% of subjects were found to have periodontal pockets. Population prevalence estimates were 45% for loss of attachment of ≥5 mm and 10% for probing depth >5 mm.35,36 Since then, some studies at a local/regional level have evaluated the dental status of specific populations, such as students (Toulouse), pregnant women (three French regions), or workers (Northern region).37,38,39
Data regarding the oral health of older people are also scarce. Several studies initiated by the public health insurance scheme were conducted between 2001 and 2006 with similar findings, indicating high dental need among institutionalised populations. As an example, 321 elderly persons from several geriatric institutions in Montpellier were examined in 2004. The prevalence of edentulism was 27%. Oral hygiene was unsatisfactory for 60% of the population. Most of the subjects needed dentures (53%), 45% required extractions and 31% restorative treatment.40
France is characterised by high health disparities. Persons benefiting from the CMUc coverage, with lower incomes or lower socio-economic status, have more carious teeth and more missing teeth compared to less deprived persons, indicating higher incidence of oral disease but also lower access to dental care.41,42,43 Moreover, it has been reported that socially disadvantaged people experience greater impact from oral disorders as measured by questionnaires on self-perceived oral health.44 Besides social disparities, there are some other groups at high risk for oral diseases, such as people with disabilities, who have very limited access to dental care. Special care dentistry is poorly recognised and services depend on local initiatives which are unevenly distributed nationally. Neither conscious sedation nor general anaesthesia are readily available for those who need it. In 2004–2005, a representative sample of 2,487 children and 4,772 adolescents/young adults with disabilities were compared to their peers without disabilities, and the level of untreated dental problems in this population was found to be very high with 18–24% of children having incipient carious lesions, 7–9% oral infections and 11–18% dental plaque.45
Access to and use of the oral healthcare system
There are no reliable data available on the use of the oral health system. According to the 'Eurobarometer 330′ of 2009, 52% of the French people declared having attended a dentist within the last year.46 Within the French system, patients mainly visit a dentist when in need of curative treatment and less often for prevention. In 2002, a quarter of the adults from a sample in the Paris region said that they had seen a dentist for preventive reasons.47 In 2000, another study indicated that 39% of the respondents declared having visited a dentist for preventive reasons in the last 12 months.48
Overall, 95% of people reported benefiting from complementary health insurance in 2014, 89% through a private/mutual insurance company and 6% through state funded CMUc coverage.49 The proportion of patients with complementary insurance could be improved if all those eligible exercised their right to additional benefits; 28% to 40% of people eligible for CMUc and 59 to 72% of those eligible to ACS do not take up these schemes.50 Lack of take-up of dental treatment for financial reasons is frequent. In 2012, a survey showed that 26% of people declared having declined or not sought dental treatment for financial reasons. Of the persons concerned, 16.2% had complementary health insurance, 21.6% benefited from the CMUc and 41.4% were without complementary health insurance.49
However, financial reasons are not the only barriers to dental treatment.51 Two telephone surveys found that up to 40% of practitioners refused to accept CMUc patients. These studies were conducted in suburban Paris, which is not representative of the whole country.52,53 Different results were found in two rural areas where the refusal rate was lower (5% to 13%).54 This may be explained by the fact that dentists tend to adopt exclusion strategies for low-income patients, considering that they often are irregular dental attenders.55
Another issue is that there is no tradition of fixed period dental recalls in France, which affects regular dental attendance. As an example, in 2006 before the implementation of the M'T dents programme, only 28% of 6-year-olds had visited a dentist over the last year.56 This rate has increased progressively with the M'T dents programme with 50% of 6-year-olds benefiting from a preventive examination in 2012.57
As described, the oral health system is successful in that it provides access to affordable dental treatment for the majority of the French population.
However, the system has two major drawbacks. The first is that it is extremely expensive. France had the highest health expenditure, as a share of GDP, of all EU Member States in 2008.58 The second problem is that of oral health inequalities, which are exacerbated rather than tempered by the health insurance system. Groups that suffer exclusion include socially deprived people, persons with disabilities, dependent elderly (absence of accommodation within the system for persons with special needs), persons living in rural areas or areas of suburban poverty. The service is clearly organised around a medical, treatment-based model. Although the vast majority of dentists work in the primary care sector they do not have a community or social mission, and surgeries are run as small businesses. The patient traditionally only attends at the onset of problems and the general expectation is of cure by intervention. There is no community dental service. There is no Chief Dental Officer or active dental public health system, and therefore there is virtually no epidemiology, goal-setting, prioritisation of services, accountability, or oral health promotion.
Certain solutions to these problems lie within the public health arena and could start to be addressed with the creation of a dental public health service with political recognition. This service would need to develop measures to help address the social determinants of oral health and to put in place a national system of oral health promotion. These activities integrated within national politics could be linked with measures taken in other domains, including education, social welfare and general health. The subject of community participation and empowerment would also have to be addressed. Reorientation of a treatment-based service to a preventive model would require initial investment but might result in a reduction of both oral health inequalities and in treatment need. Investment would be necessary to train and enrol professionals complementary to dentistry who could undertake oral health promotion and education activities at a community level. These activities would need to be guided and evaluated by the dental public health service.
Solutions could also be found through the reorientation of treatment services. Primary dental care needs to be reinforced by focusing on local care providing for all the essential treatment needs of the vast majority of patients at a community level. The definition of 'essential care' needs to be re-evaluated within the public health insurance fee scale, ensureing dentists not to have to work at a loss when providing basic restorative or preventive care. To offset this additional cost to the system, access to public funding of high-cost treatment, particularly in the secondary care sector, could be better regulated. Moreover, a clearer definition of the tertiary care system would need to support the role of the social mission of public hospital services. Means of including marginalised groups within the primary care system also need to be developed. Dentists with evidence of expertise and willingness to treat certain populations ('dentists with a special interest') could be accorded an augmented public health insurance fee scale according to case-mix.
In terms of increasing access to care while reducing costs, France could move into line with other European countries and create the professions of dental hygienist and dental therapist. This would aid the move towards a more preventive health system, while freeing dentists to undertake the treatment that they alone have the expertise to provide. Issues of quality and access to care might also be addressed if the profession of dental nurse were officially recognised. The government is currently discussing a proposition for the official registration of dental nurses. In addition, an independent inquiry has made recommendations that would define the role of the dental nurse, including provision of oral health promotion and basic preventive care in residential care for example, under the responsibility of a qualified dentist.11 The French dental council (OCD) supports this evolution but the dental trade unions are as yet divided by the question. Another means of aiding a shift away from a medical model of care would be the reorientation of undergraduate, postgraduate and continuing education towards a patient-centred approach rather than a traditional technique- or discipline-based, standpoint.
It is unlikely that the system will integrate such change in the near future, partly because the move from a medical model to a prevention-based system would imply massive restructure and would need to be carried by strong political conviction. The financial restrictions currently imposed on the public system in France, as elsewhere in Europe, might however act as an incentive for the state to try to find less onerous, up-stream solutions to the nation's oral health needs.
EP-M: Researched and wrote the first draft of the sections 'Dental treatment', 'Oral healthcare costs', 'Oral healthcare workforce' and 'Access to and use of the oral healthcare system'; and collaborated on all subsequent drafts of the manuscript.
DF: Wrote the abstract, introduction and discussion; collated the sections from each author to produce a second draft; and collaborated on all subsequent drafts of the manuscript.
KE and EW: Commissioned the paper as part of a series on the different health and oral healthcare systems in Europe, provided a template for structure; and provided comments and suggestions for the final draft of the manuscript.
PH: Researched and wrote the first draft of the sections 'French healthcare system' and 'Costs and financing'; contributed to researching and writing the sections on the oral healthcare system; and collaborated on all subsequent drafts of the manuscript.
ST-J: Coordinated the work, researched and wrote the first draft of the sections 'Dental education', 'Prevention and oral health promotion' and 'Epidemiology'; and collaborated on all subsequent drafts of the manuscript.
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Pegon-Machat, E., Faulks, D., Eaton, K. et al. The healthcare system and the provision of oral healthcare in EU Member States: France. Br Dent J 220, 197–203 (2016). https://doi.org/10.1038/sj.bdj.2016.138
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