Exceeding fundamental fees through scientific experts is turning into extra common, or even the bulk for positive remedies and in positive territories. Contemporary research through the Institute for Analysis and Documentation in Well being Economics (Irdes) display that positive procedures are of explicit fear, comparable to cataract surgical operation, cruciate ligament reconstruction, “sleeve gastrectomy” and even hip alternative. This remark raises questions on get right of entry to to deal with all, particularly for families whose assets are somewhat above the edge for the use of the care device meant for probably the most modest families.
Overpayments have change into a fact for increasingly more French folks. This fairly technical time period refers to an extra worth charged through positive non-public docs over and above the traditional Social Safety price – and due to this fact incessantly paid through the affected person. For the reason that rule is discreet: Social Safety does no longer catch up on those excesses.
Subsequently, they continue to be the affected person’s accountability…except their complementary medical insurance (incessantly referred to as “mutual” even if no longer coated through the Reciprocity Code) assumes accountability. On the other hand, this relay could be very asymmetric and incessantly incomplete, when it’s not there: in general, most effective 40% of those prices are coated on moderate through supplementary medical insurance.
Subsequently, an important a part of the prices stays immediately borne through families. Via this fact, the monetary availability of care is immediately wondered.
A phenomenon that isn’t new
This remark isn’t fresh. Within the early Eighties, all through the negotiations for a brand new settlement between Medicare and docs, the latter demanded an build up of their costs. However this request runs into the monetary difficulties of medical insurance.
To handle this case, the federal government comes to a decision to create two typical sectors:
in sector 1, docs adopt to admire the price lists set through the medical insurance…
in sector 2, docs can set upper costs through not easy further charges from sufferers.
Within the Nineties, a pointy build up within the collection of docs choosing sector 2 ended in fears of a mass shift in opposition to this mode of observe. To decelerate this motion, get right of entry to to sector 2 is specific to docs with positive health facility {qualifications} – particularly former heads of clinics and health facility assistants. As those pathways are particular to specialist docs, normal practitioners are in observe excluded from the device. Those that are nonetheless operating in sector 2 as of late due to this fact accessed it earlier than this “freeze”, and is the reason their very small proportion.
Within the 2010s, within the context of a being worried build up within the stage of extra, law moved in opposition to incentive mechanisms to mitigate the surplus: first the Healthcare Get entry to Settlement (CAS) in 2012, changed in 2016 through the Managed Worth Follow Possibility (Optam). Medical doctors who subscribe to it adopt for 3 years to not build up costs, to stabilize the speed of extra charges and the percentage of procedures they convey out with out exceeding.
If truth be told, those mechanisms of worth law and preparations for overlaying overcharges through complementary medical insurance firms are complicated. Added to that is incessantly the loss of visibility for the affected person of the extent of extra that can be implemented to them. Below those prerequisites, it’s tricky for him to estimate the volume that may stay his accountability.
These days this can be a common observe amongst docs
In 2024, consistent with the Prime Council for the Long run of Well being Insurance coverage (Hcaam), 56% of personal experts (consulting in non-public drugs) paintings in sector 2, in comparison to 37% in 2000. During the last two decades, the proportion of personal docs in sector 2 has higher considerably in all specialties.
It reaches, as an example, 86% amongst surgeons and 72% amongst ophthalmologists. Amongst dermatologists, that proportion is round 50%. To the contrary, for positive specialties comparable to cardiology or radiology, it’s nearer to a 3rd (31% in cardiology, 35% in radiology in 2024).
In 2024, the typical overage price for sector 2 docs can be 50%. Which means that, on moderate, a process for which the medical insurance price is 100 euros is invoiced for 150 euros (alternatively, once we restrict ourselves most effective to the surplus procedures, this quantity in fact quantities to 189 euros.
However this moderate price of fifty% varies extensively through uniqueness and through practitioner: as an example, in 2024 it used to be 60% amongst surgeons, however about 20% amongst cardiologists or pulmonologists.
Even inside of the similar uniqueness, overcharging practices range a great deal from one doctor to any other and will achieve top ranges: as an example, amongst non-public sector surgeons 2, the overcharging price exceeded 184% for the ten% of surgeons with the perfect overcharging in 2023.
Supporting examples: a ways from marginal excesses for sufferers
The Institute for Analysis and Documentation in Well being Economics (Irdes) has performed a number of research to give a boost to the paintings of the Prime Council for the Long run of Well being Insurance coverage (Hcaam). Some purpose to objectify the frequency and quantities that overpayments in fact constitute for sufferers having access to positive specialties, positive procedures or episodes of care and relying at the territory.
Irdes thus analyzed the costs charged for a choice of 14 not unusual technical procedures, in response to information from the Nationwide Well being Information Device (SNDS). The consequences display that for positive procedures the percentage of sufferers who have been overcharged is top.
For instance, in 2021, seven out of ten autograft ACL reconstructions led to a median far more than €535.
For laparoscopic sleeve gastrectomy for morbid weight problems, 58% of sufferers needed to pay an overpayment of a median of €880, however greater than €1,500 in 10% of circumstances.
However the act of care isn’t remoted: surgical intervention is maximum incessantly related to session and the act of anesthesia, pre- and/or postoperative imaging, and so on. On this case, extra prices is also the accountability of various docs and gather all through all the episode of care.
In any other learn about, Irdes analyzed those cumulative occurrences for 4 widespread care episodes related to 4 health facility procedures: childbirth, lens surgical operation, general hip alternative, and colonoscopy.
In 2021, somewhat a couple of in two sufferers who had an clear-cut vaginal supply have been uncovered to excesses all through an episode of care, for a median quantity of 300 euros.
However for hip replacements, 79 % of sufferers (or nearly 8 out of ten) have been overcharged, at a median of €700, with the invoice exceeding €1,400 in 10 % of circumstances.
Subsequently, for lots of remedies or episodes of care, the want to settle the surplus has change into the commonest state of affairs for the affected person as of late.
There are nearly no overages in neighborhood cardiology or for vaginal supply
For positive remedies, the so-called fixed-tariff be offering (particularly that equipped through public hospitals or non-public sector 1 docs) stays in maximum and in most cases to be had in maximum territories.
That is, as an example, the case with acts of herbal childbirth, which in 59 departments nearly by no means (in additional than 95% of circumstances) motive an far more than charges for the gynecologist-obstetrician who carried out it.
The similar applies to city cardiologists who observe three-quarters in sector 1, which permits sufferers to get right of entry to the be offering with out extra in maximum territories, excluding in positive extremely urbanized departments or areas, comparable to Ile-de-France or Gironde.
Get entry to ranges (APL) to cardiologists consistent with the scope of the be offering
The darker the colour, the upper the collection of contacts in keeping with 100 population. Supply: “Spatial Inequalities in Access to Specialist Doctors. Proposed Indicators”. Irdes, October 2025 (clickable maps). Those territories the place the supply of care with out extra has disappeared
By contrast, for different care, sector 2 expanded considerably. In maximum territories, geographic availability then is based closely on those practitioners, which from time to time makes it tricky to keep away from overruns.
That is particularly the case in neighborhood ophthalmology and dermatology.
Affordability ranges (APL) to ophthalmologists consistent with the scope of the be offering
The darker the colour, the upper the collection of contacts in keeping with 100 population. Supply: “Spatial Inequalities in Access to Specialist Doctors. Proposed Indicators”. Irdes, October 2025 (clickable maps).
We additionally practice this phenomenon with sleeve gastrectomy: in 61 departments a couple of out of 2 procedures results in an extra, and in 16 departments greater than 3 out of 4.
On the other hand, the profile of sufferers paying those excesses is immediately dependent at the availability of no-excess choices, which range extensively through care. The paintings of Irdes thus displays that once the provision on the reverse worth (public hospitals, non-public non-profit and establishments of the liberal sector 1) is within the majority and smartly dispensed through territory – so far as childbirth is anxious – the excesses basically fear sufferers from probably the most favorable municipalities.
Conversely, when sector 2 is dominant, as in cruciate ligament reconstruction, the excesses are normally dispensed throughout all affected person profiles, together with the ones from probably the most prone municipalities.
Is common get right of entry to to care in danger?
A long way from representing marginal scenarios, those configurations have a tendency to change into the norm in increasingly more territories and specialties. As inexpensive provide declines, get right of entry to to excess-free care is not assured and depends upon the place the affected person lives, the kind of care, and in the long run the assets of the affected person.
This query isn’t raised within the legislation for probably the most insecure insured individuals: nearly 8 million folks as of late use complementary harmony medical insurance (C2S), a device meant for folks with little assets, for whom the invoicing of extra advantages is illegitimate through legislation.
Then again, there is not any identical coverage for all different insured individuals. In territories and specialties the place the be offering on the appropriate worth (no extra) is lowered, excesses if truth be told change into tricky to keep away from, together with sufferers with modest assets, however above the eligibility threshold for complementary solidary medical insurance.
On the present price of installations in sector 2 (permitting overcharges), it sort of feels tricky to deal with momentum. By way of 2040, sector 2 may just constitute nearly 89 % of specialist docs in non-public observe, whilst the entire quantity of extra charges would exceed 10 billion euros, in comparison to 4.7 billion in 2025.
This type of trajectory acutely raises the problem of equitable get right of entry to to care, as illustrated through fresh paintings through the Prime Council at the Long run of Well being Insurance coverage, which explores a number of eventualities for reforming doctor overpayments.
The query turns into central: will the French well being device stay in response to common get right of entry to to care, unbiased of the affected person’s assets and their position of place of dwelling, or will it evolve in opposition to a type the place the extent of complementary well being protection and the facility to pay will more and more situation efficient get right of entry to to specialist docs?
