Out-of-pocket payments (OOP) correspond to health care expenses to be paid by the patients after reimbursement by the National Health Insurance (NHI): copayments, non-refundable deductibles and extra fees of professionals of health. They can represent a heavy burden on individuals' budgets: indeed, if access to complementary health insurance (CHI) is almost universal (more than 9 out of 10 persons), the quality of the CHI depends on their income. The level of out-of-pocket payments remains a barrier to access to care for patients in need. However, in spite of measures to limit them, particularly for the sickest people - the Long-Term Diseases (ALD) system - the amounts of certain OOP and their concentration on certain populations question the current system of health care funding. We analyze in this study the 10% of individuals with the highest OOP, that is to say those higher than 1 110€ in 2010, by identifying the care items that most contribute at these high levels. We identify four profiles described in terms of their health status, socio-economic characteristics, and the amounts of co-payments, non-refundable deductibles and extra fees.
The matching of the Health, Health Care and Insurance Survey (ESPS) to the National Health Insurance data makes it possible to enrich the administrative data and thus to have information on the characteristics of individuals with high OOP, in terms of health status, income and also complementary health insurance. We have thus developed a typology of profiles of persons supporting the highest OOP. Four profiles are distinguished. Profile 1 (26% of the studied population) concerns chronically ill patients, mostly women, who are treated as outpatients and whose OOP amount 1 942€ on average. Profile 2 (12% of the population studied) is distinguished by the highest amount of OOP, 2 134€, and concerns inpatients in the public, rather vulnerable. Profile 3 (24% of the studied population) is made up of more active men, whose OOP -1 920€ on average-, are explained by dental expenses. Profile 4 (38% of the studied population) is made up of non-hospitalized seniors, whose OOP amount 1 775€ on average, resulting from the recurrence of co-payments for ambulatory items associated with the disease (doctors, pharmacy...), but also for eyewear purchases. High OOP often result from the accumulation of different types of OOP and are not restricted to chronically ill persons. Only 4 out of 10 of those with high OOP are chronically ill or have been admitted to hospital at least once a year.
Almost one-third of the 10% of those with the highest OOP in 2010 still seems to bear the burden in 2012. And if all profiles see the amount of their OOP falling on average, profiles 1 and 4 are characterized by a higher proportion of people still bearing high OOP in 2012. For profile 1, for example, 50% of individuals - suffering from a chronic illness and mainly treated as outpatients - continue to support heavy OOP in 2012. For profile 4 - non-hospitalized seniors - 32% among them remain among the 10% of individuals with the highest OOP in 2012. These results must be put into perspective with the heterogeneity of the complementary health insurance (CHI) contracts. Indeed, some or all of these OOP will be ultimately reimbursed by the CHI. The prospect of matching the compulsory National Health Insurance data with CHI data under the National Health Data System (SNDS, Système national des données de santé) should make possible to increase the knowledge of OOP.
Interview by Anne Evans