Article 80: A Shift in Patient Transport Funding

The landscape of patient transport funding in France underwent a significant transformation with the introduction of Article 80 of the 2017 Social Security Financing Law (LFSS 2017). This pivotal article, which officially came into effect on October 1st, 2018, has been a subject of considerable debate within the healthcare sector, particularly for taxi professionals. At its core, Article 80's primary objective was to realign the financial responsibility for patient transport expenses, moving them from the direct purview of health insurance (Assurance maladie) to the healthcare establishments themselves.

This strategic shift was implemented with the overarching goal of streamlining healthcare expenditure and achieving cost reductions. The move was formalised following the publication of Decree No. 2018-354 on May 15th, 2018, which detailed the specific modalities and scope of coverage for the transport of hospitalised patients. As stipulated in Article L.162-21-2 of the Social Security Code, the new framework dictates that 'transports carried out within the same healthcare establishment or between two healthcare establishments are covered by the establishment originating the transport prescription and are included in their tariffs.'

Scope of Services Affected by Article 80

To clarify the practical implications of this legislative change, the Primary Health Insurance Fund (Caisse primaire d’Assurance maladie) issued a letter on September 17th, 2018, outlining the specific types of transport that fall under the new provisions. These include:

• Transfers between two healthcare facilities, whether they are temporary (less than 48 hours) or permanent.
• Transport related to patient leave of absence for medical reasons or due to the closure of a healthcare facility.
• Transport associated with services provided 'off-site' or outside the traditional facility setting.

It is important to note that while the aim was to shift the burden, certain patient journeys remain under the coverage of the Assurance maladie. The same letter from September 17th, 2018, also enumerated these exceptions, ensuring that not all patient transport costs were unilaterally transferred.

Key Changes Introduced by the Article 80 Reform

The reform, spearheaded by the government with the intention of generating savings for the Assurance maladie, has been more widely recognised as 'Article 80 of the LFSS 2017'. This reform began to take concrete shape with the dissemination of an information note on March 19th, 2018. This note provided crucial clarifications on various aspects, including the precise scope of the reform and the specifications for future public procurement contracts.

Clarifications on Transport Covered by the Article 80 Reform

The information note, accompanied by two detailed annexes, reinforced the fundamental principle underpinning the Article 80 reform. The core tenet is clearly articulated: 'The general principle is as follows: any transport of a patient who is already hospitalised is no longer billable to health insurance but is covered by the prescribing establishment.'

A critical element here is the definition of a 'patient already hospitalised'. This condition is the absolute prerequisite for the application of the reform. Annex 1 of the note further elaborates that inter-establishment transport for 'a patient not hospitalised at the time of transfer' remains billable to the Assurance maladie. This distinction is paramount in determining the applicability of the new funding model.

Once a patient is hospitalised, any definitive transfer to another healthcare establishment, whether it falls under MCO (Medicine, Surgery, Obstetrics), SSR (Convalescence, Rehabilitation, and Functional Re-education), Psychiatry, or Home Hospitalisation, is to be billed to the prescribing establishment – that is, the patient's original facility. The same applies to provisional transport under specific conditions:

• Transfers between two establishments where both facilities operate within the same sector (e.g., MCO to MCO).
• Transport linked to a medically justified leave of absence.
• Transfers to a private practice or a health centre.
• Transport for off-site medical procedures such as dialysis sessions, radiotherapy, or chemotherapy.

It is worth noting that in the latter two scenarios, the billing responsibility might not always fall on the originating establishment but could be transferred to the receiving facility, depending on the specific circumstances. Nevertheless, in all these instances, such transport falls within the scope of the reform.

Public Procurement Specifications for Transport Services

Beyond the invoicing adjustments, a significant change brought about by the Article 80 reform is the application of Public Procurement Codes for the awarding of Transport Assistance Professionnelle (TAP) contracts. This aspect is particularly crucial as it has the potential to create complex and challenging situations for independent taxi operators, who may face increased competition from larger service providers.

In Annex 2 of the March 19th, 2018 note, which provided an example of the specifications for public procurement, several points were clarified by the government following negotiations with trade unions. Notably, the contracts will be divided into two distinct lots: the first for transports requiring an ambulance, and the second specifically for professionalised seated transport. This segmentation aims to ensure that different types of patient transport needs are met appropriately.

The government, in response to the demands of trade unions such as the UNT (Union Nationale des Taxis), has indeed limited the eligibility to bid for these tenders to recognised health transport services (VSL) and contracted taxi companies. Furthermore, the 'price criterion' will now account for only 40% of the overall evaluation score for submitted bids, with the remaining 60% allocated to technical quality and organisational proposals. This adjustment is designed to mitigate the disadvantage that independent taxis might face due to potentially higher pricing compared to larger corporate entities.

Preservation of Employment in Case of Market Loss

An additional safeguard was explicitly detailed in the March 19th, 2018 note: the provision for the continuation of employment in the event of a company losing a contract. This measure aims to protect jobs should a company fail to secure a contract following the tenders issued by healthcare establishments.

Article L. 1224-1 of the Labour Code, which has been extended to service contracts and, consequently, public procurement, states that 'when a modification occurs in the employer's legal situation, notably through succession, sale, merger, transformation of the business, or incorporation into a company, all employment contracts in progress on the date of the modification shall remain in effect between the new employer and the company's personnel.'

Consequently, according to the note, 'healthcare establishments must include a clause in their contracts to inform providers that in the event of a 'takeover' of the contract, employees of the company who were not selected for the new contract may be automatically transferred to the structure of the new provider.' This transfer, however, is subject to specific conditions to ensure a smooth transition for both the employees and the service providers.

Discussions between public authorities and trade unions are ongoing, as numerous points still require further clarification. The reform, initially planned for an earlier implementation, was postponed to October 1st, 2018, following successful negotiations by taxi unions in 2017, allowing for a more considered and prepared rollout.

Frequently Asked Questions about Article 80

Q1: Who is now responsible for the cost of patient transport?
A1: Healthcare establishments are now responsible for the cost of patient transport, particularly for patients who are already hospitalised and are being transferred between facilities or for specific medical reasons.

Q2: What types of transport are covered by Article 80?
A2: Article 80 covers transfers between healthcare facilities (temporary or permanent), transport related to medical leave, and transport for off-site medical procedures.

Q3: Are there any exceptions where health insurance still covers transport costs?
A3: Yes, health insurance may still cover transport costs for patients who are not hospitalised at the time of transfer, and in certain specific cases outlined by the health authorities.

Q4: How does Article 80 affect taxi companies?
A4: Article 80 introduces new public procurement rules for awarding transport contracts, potentially increasing competition. However, measures have been put in place to favour quality and organisation, and to protect employment.

Q5: When did Article 80 come into effect?
A5: Article 80 officially came into effect on October 1st, 2018.

In conclusion, Article 80 of the LFSS 2017 represents a significant recalibration of financial responsibilities within the French healthcare system concerning patient transport. While aiming for cost efficiencies, it has introduced new operational and competitive dynamics for transport providers, particularly taxi services, necessitating careful adaptation to the revised regulatory framework.

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