Risk management is at the centre of an insurer's activity. It consists in controlling the expenditure development while improving the population health. In France, 55 million people are insured at the general health insurance scheme.
Five main tendencies
In the August-2004 reform context, Health Insurance defined its programme and its actions as far as risk management is concerned. On the general director's proposal, five main tendencies were adopted by the CNAMTS' Council in 2005.
They concern the following topics:
- Prevention development in order to contain healthcare expenditure, which means acting on behaviours before the development of a disease.
- Information and support regarding all the system actors, particularly insured people and healthcare professionals.
- Useless expenditure limitation through the control of reimbursed care, tariff fixing, medical justification to receive care.
- Healthcare offer organization.
- Healthcare system steering and control.
Expenditure medical control : a risk management tool
Medical control aims at getting more productivity for healthcare system. This increase in productivity is possible thanks to the development of behaviours in terms of prescriptions for treatments and care consumption.
Medical control of expenses is based on the following principles:
- Medical references.
- Quantified aims which are negotiated with healthcare professionals and written on contracts.
- Dynamics concerning national programmes transformed into actions thanks to the whole health insurance regional and local network.
