Abstract

Background: Complementary Universal Health insurance (CMUC) providing free access to health care has been available in France, since 2000 for people with an annual income <50% of the poverty threshold. Methods: Data were derived from the French national health insurance reimbursements and short-stay admissions database for 2007 (80% of subjects under the age of 60 years in France, including 4.8 million CMUC beneficiaries). Rate ratios were calculated by dividing the rate of CMUC beneficiaries by that of other beneficiaries standardized for the sex and age distribution of CMUC beneficiaries. Results: The hospitalization rate of CMUC beneficiaries was 17.2% and the standardized rate for non-CMUC beneficiaries was 13.2% (ratio: 1.3). It was equally raised regardless of gender and age of CMUC beneficiaries. The hospital mortality rate was 0.61% for CMUC beneficiaries and the adjusted rate for non-CMUC beneficiaries was 0.35% (1.8). The hospitalization ratio for CMUC beneficiaries was >1 for all of the 22 major diagnostic categories, including psychiatry, toxicology and alcohol (3.7), HIV (3.3), infectious diseases other than HIV (1.9), burns (2.6), trauma (1.7) and female genital tract tumours (1.6) but not breast tumours (0.8). Hospitalizations for investigations such as endoscopies were also more frequent, as well as stays of <48 h for radiotherapy (1.6), chemotherapy (1.5) and dialysis (2.2). Conclusions: In this low-income population with free access to health care, hospitalization and hospital mortality rates were higher for many diseases that are known targets for prevention and screening actions.

Introduction

People with a low socio-economic level are in less good health and have a shorter life expectancy.1–5 They have more complex and major health care needs and experience difficulties of access, which have been improved by full health insurance coverage. They more frequently seek medical attention in hospital than in office medicine, especially for specialist consultations.6–13 Expressed morbidity and diseases or specific disease groups have been essentially studied in this low-income population, characterized by low income, education or socio-economic levels, but their hospitalization rate and the associated diagnoses have been rarely studied.14–31

The French national health insurance (NHI) is offered to all citizens regularly living in France. Globally, it supports ~80% of hospital costs; it also covers medications expenditures between 35% and 65% of their cost; medical consultations are refunded on the basis of an agreed price set by the NHI and reimbursed at 70% of this NHI rate. To get reimbursement for the difference between actual treatment cost and NHI refund, French residents may choose to get affiliated to supplemental private insurances, but affiliation to such insurances is highly linked to the patients’ income levels.32 In 2000, France adopted Couverture Maladie Universelle Complémentaire [Complementary Universal Health Insurance] (CMUC), which provides full health care coverage according to the current reimbursement ceiling without advance payment by beneficiaries. It is available to an annual income ceiling (~€7500 in 2007), below the poverty threshold defined in France (50% of the median income, i.e. ~€9000). People covered by the CMUC do not have to pay first for being reimbursed later; both the hospitals and physicians are paid by the insurance system directly. At the end of 2007, 7% of the 63.5 million inhabitants in France were CMUC beneficiaries. As in other countries, information systems, especially hospital-based systems, do not routinely collect data on individual social characteristics, which makes it difficult to study social inequalities.33 This absence of data can be palliated by specific studies on samples of aggregated geographical socio-economic data or by health insurance information systems, which can record reimbursement conditions according to income or other social characteristics.

This study was designed to estimate hospital admission and hospital mortality rates of CMUC beneficiaries, a large low-income population with free access to health care, to compare them with those of the non-CMUC beneficiaries of the main French NHI scheme by hospital diagnosis.

Methods

Study population

The general scheme, Health Insurance Fund for Salaried Workers (CNAMTS), covers ~70% of the population residing in France with also people (16%) with specific complementary refund (students, state employees). The National Health Insurance Fund for Agricultural Workers and Farmers (MSA) and the National Health Insurance Fund for the Self-employed (RSI) cover 5% each with 12 additional schemes covering the remaining 4%. We included the population covered by the CNAMTS scheme (70% of French population), totalizing 80% of the 56 million people under the age of 60 years and 91% of CMUC beneficiaries (5.3 million). People aged ≥60 years were not included, as subjects in this age group with low-annual income are eligible for a specific allowance which exceeds the CMUC means test. The CMUC is granted for 1 year on the condition of regularly and stably residing in France for >3 months. Beneficiaries under the age of 60 years were included in the study and categorized according to their CMUC status in 2007. The applicant’s household can include the applicant, the applicant’s spouse, de facto partner, children and other people under the age of 25 years living under the same roof. The CMUC means test varies according to the number of people in the household and is higher in overseas departments (€8300 vs. €7500 for a single person).

Setting and design

The 2007 data extracted from the French national health insurance (NHI) reimbursement and short-stay hospital admissions database were retrospectively analysed.

Data sources

The French national health insurance information system (SNIIRAM) contains individualized, anonymous and comprehensive data on all beneficiaries and their health spending reimbursements.34 Other information is also recorded, such as the existence of universal health care coverage and complementary health insurance (CMUC) and individual demographic characteristics. The French medicalized information system programme (PMSI: programme de médicalisation des systèmes d’information) is used for hospital payment and provides medical information for all patients discharged after each hospitalization from both public and private hospitals. Diagnoses recorded in the PMSI are coded according to the International Classification of Diseases, 10th Revision and are then grouped by GHM/DRGs according to an algorithm validated by the Agence Technique de l'Information sur l'Hospitalisation (ATIH, www.atih.sante.fr) [Technical Hospitalization Information Agency], and then into 201 subgroups comprising DRGs corresponding to the same diagnosis but with various levels of associated complications. They are grouped into 24 groups representing activity poles. Hospitalization involving transfer from one facility to another (e.g. for other specialized care) was considered to be a single admission. Hospital mortality was defined as death during hospitalization recorded in the PMSI database. Hospitalizations of French national health insurance scheme beneficiaries from January to December 2007 were extracted from the national PMSI database focusing on short-term hospital stays (medicine, surgery and obstetrics units) and linked to the reimbursement database using a common, anonymous patient number. CMUC beneficiaries in 2007 were defined by attribution or renewal of CMUC cover in 2007.

Statistical analysis

Crude annual hospital admission or hospital mortality rates were defined as the number of admissions or hospital deaths for CMUC patients or not per 100 or 100 000 individuals of each group. Adjusted rates were then calculated for non-CMUC patients on the basis of the age and sex distributions of the CMUC group. Rate ratios were calculated by dividing CMUC rates by adjusted non-CMUC rates; rate ratios >1 indicate more admissions or deaths for CMUC beneficiaries and rate ratios <1 indicate fewer admissions. Ninety-five percent confidence intervals are not reported, as this study was based on the total general scheme population and large numbers of individuals with or without CMUC coverage. Rate ratios are reported for diagnoses classified into 24 groups and 201 subgroups. Only subgroups with hospitalization rates >0.01% and rate ratios >1.1 or <0.9 are reported. Non-specific subgroups classified as ‘other’ for each group are also not reported. Data were analysed using SAS statistical software (SAS version 9.1.3, SAS Inc, Cary, NC, USA).

Results

Among the 40.155 million non-CMUC beneficiaries covered by the French national health insurance general scheme, 5.297 million patients accounted for a total of 7.407 million hospital stays, i.e. 1.4 stays per hospitalized patient with a mean length of stay of 3.1 days. For the 4.791 million CMUC beneficiaries, 0.824 million patients accounted for a total of 1.239 million hospital stays, i.e. a mean of 1.5 stays and a mean length of stay of 3.5 days. These patients represented 10.7% of all general scheme beneficiaries, 13.4% of all hospitalized patients and 14.3% of all hospital stays. CMUC beneficiaries were more often women (55% vs. 52%) and were younger than non-CMUC beneficiaries: 0–19 years (44.9% vs. 31.8%), 20–39 years (33.1% vs. 33.8%), 40–59 years (22% vs. 34.4%).

The annual standardized hospitalization rate was 13.2% for non-CMUC beneficiaries and 17.2% for CMUC beneficiaries with a 1.3-fold higher rate ratio (table 1). This rate ratio was similar for men and women and for the age groups studied. It was 1.6 for obstetric hospitalizations, 1.5 for medicine hospitalizations and 2.2 for dialysis sessions.

Table 1

Hospitalization and hospital mortality rates according to health insurance coverage, characteristics of the beneficiaries and type of hospitalization in 2007

 Hospitalization
 
Hospital mortality
 
 CMUC Non-CMUC
 
Rate ratioa CMUC Non-CMUC
 
Rate ratioa 
 Crude rate (%) Crude rate (%) Standardized rate (%)  Crude rate (%) Crude rate (%) Standardized rate (%)  
All 17.2 13.2 13.0 1.3 0.61 0.54 0.35 1.8 
Males 15.1 11.5 11.4 1.3 1.00 0.8 0.53 1.9 
Females 18.9 14.7 14.3 1.3 0.36 0.35 0.23 1.6 
0–19 years old 13.9 10.9 11.1 1.3 0.12 0.09 0.09 1.3 
20–39 years old 20.3 13.6 14.4 1.4 0.23 0.15 0.14 1.7 
40–59 years old 19.4 14.6 14.6 1.3 1.93 1.18 1.10 1.8 
Hospitalization         
    Surgery 6.1 5.8 5.4 1.1 0.18 0.13 0.09 2.0 
    Medicine 9.2 6.5 6.3 1.5 1.02 0.96 0.67 1.5 
    Obstetrics 3.6 2.0 2.3 1.6 – – – – 
Stay <48 h         
    Chemotherapy 0.14 0.17 0.12 1.2 – – – – 
    Radiotherapy 0.04 0.13 0.04 1.2 – – – – 
    Dialysis 0.03 0.02 0.01 2.2 – – – – 
    Transfusion 0.03 0.02 0.02 1.7 – – – – 
 Hospitalization
 
Hospital mortality
 
 CMUC Non-CMUC
 
Rate ratioa CMUC Non-CMUC
 
Rate ratioa 
 Crude rate (%) Crude rate (%) Standardized rate (%)  Crude rate (%) Crude rate (%) Standardized rate (%)  
All 17.2 13.2 13.0 1.3 0.61 0.54 0.35 1.8 
Males 15.1 11.5 11.4 1.3 1.00 0.8 0.53 1.9 
Females 18.9 14.7 14.3 1.3 0.36 0.35 0.23 1.6 
0–19 years old 13.9 10.9 11.1 1.3 0.12 0.09 0.09 1.3 
20–39 years old 20.3 13.6 14.4 1.4 0.23 0.15 0.14 1.7 
40–59 years old 19.4 14.6 14.6 1.3 1.93 1.18 1.10 1.8 
Hospitalization         
    Surgery 6.1 5.8 5.4 1.1 0.18 0.13 0.09 2.0 
    Medicine 9.2 6.5 6.3 1.5 1.02 0.96 0.67 1.5 
    Obstetrics 3.6 2.0 2.3 1.6 – – – – 
Stay <48 h         
    Chemotherapy 0.14 0.17 0.12 1.2 – – – – 
    Radiotherapy 0.04 0.13 0.04 1.2 – – – – 
    Dialysis 0.03 0.02 0.01 2.2 – – – – 
    Transfusion 0.03 0.02 0.02 1.7 – – – – 

a: Rate ratio is calculated as the ratio of CMUC rate and non-CMUC rate adjusted for age and sex distributions of the CMUC group

According to the 24 diagnosis-related groups defined, hospitalization rates for CMUC beneficiaries were always higher than those of non-CMUC beneficiaries (table 2) with rate ratios of 1.6 for obstetrics, 1.2 for gastrointestinal tract, 1.8 for ‘other’ management and 1.4 for urology–nephrology. The main diagnosis-related groups accounting for <5% of stays were: ‘psychiatry, toxicology, intoxication, alcohol’ (ratio 3.7), respiratory medicine (1.9), infectious diseases other than HIV (1.9), HIV disease (3.3) and endocrinology (1.6). CMUC beneficiaries almost systematically presented more frequent hospitalizations according to the various age groups studied (table 3). In the 0–19 years age groups, diagnosis-related groups with marked excess hospitalization rates were obstetrics, burns, ‘psychiatry, toxicology and intoxication’, respiratory medicine and multiple trauma. In the 20–39 and 40–59 years age groups, the diagnosis-related groups concerned were HIV disease, ‘psychiatry, toxicology and intoxication’, burns and infectious diseases other than HIV. The excess hospitalization rate for HIV infection among CMUC beneficiaries was higher for women than for men in the two age groups: 20–39 years (6.53 vs. 2.69), 40–59 years (4.30 vs. 2.03).

Table 2

Share of stays, hospitalization and hospital mortality rates, mean length of stay according to diagnosis groups and type of health insurance coverage in 2007

Diagnosis group Hospitalization
 
Length of stay (days)
 
Hospital mortality
 
 CMUC share (%) Non-CMUC Share (%) CMUC Crude rate (%) Rate ratioa CMUC Non CMUC CMUC Crude rate (%) Rate ratioa 
Obstetrics 17.8 13.2 3.62 1.6 3.7 4.0   
Gastroenterology 12.6 16.3 2.62 1.2 3.3 2.5 0.46 2.8 
Other reasons 10.3 9.8 1.81 1.8 2.1 1.9 2.77 1.2 
Orthopaedics, rheumatology 7.7 12.0 1.66 1.1 3.7 3.0 0.08 2.7 
ENT, Stomatology 7.7 8.1 1.85 1.1 1.8 1.6 0.07 2.1 
Newborns 7.3 6.1 1.77 1.1 6.1 5.6 0.04 0.9 
Psychiatry, toxicology, intoxication, alcohol 4.8 2.0 0.85 3.7 3.6 4.0 0.03 0.9 
Urology–nephrology 4.7 5.0 1.00 1.4 2.5 2.4 0.14 2.4 
Respiratory medicine 4.1 2.9 0.82 1.9 5.4 5.1 1.26 1.1 
Nervous system 4.0 3.5 0.84 1.7 4.5 4.4 1.14 1.3 
Dermatology 3.5 3.7 0.82 1.4 2.7 2.2 0.06 2.0 
Gynaecology 3.1 4.7 0.70 1.1 3.0 2.7 0.06 1.3 
Endocrinology 2.6 2.5 0.54 1.6 4.2 3.3 0.17 1.7 
Haematology 2.0 2.2 0.24 1.7 4.2 3.7 0.84 1.1 
Cardiology 1.8 1.9 0.41 1.7 4.1 3.5 1.41 1.5 
Ophthalmology 1.3 1.5 0.27 1.4 2.0 1.7 0.00  
HIV 1.3 0.7 0.12 3.3 3.1 2.3 1.15 1.4 
Infectious disease (other than HIV) 1.0 0.7 0.24 1.9 4.5 4.9 1.67 1.3 
Vascular 1.0 1.7 0.22 1.1 4.1 2.6 0.37 2.5 
Vascular catheter 0.8 1.1 0.19 1.6 3.8 3.4 0.39 1.2 
Chemotherapy, radiotherapy, transfusion 0.5 0.6 0.06 1.6 4.3 3.9 0.27 0.9 
Burns 0.21 0.1 0.03 2.6 7.4 6.6 0.74 1.5 
Trauma 0.05 0.1 0.01 1.7 23.9 23.2 4.25 1.1 
Unknown 0.06 0.1 0.02 1.6 6.6 5.6 0.82 0.7 
Diagnosis group Hospitalization
 
Length of stay (days)
 
Hospital mortality
 
 CMUC share (%) Non-CMUC Share (%) CMUC Crude rate (%) Rate ratioa CMUC Non CMUC CMUC Crude rate (%) Rate ratioa 
Obstetrics 17.8 13.2 3.62 1.6 3.7 4.0   
Gastroenterology 12.6 16.3 2.62 1.2 3.3 2.5 0.46 2.8 
Other reasons 10.3 9.8 1.81 1.8 2.1 1.9 2.77 1.2 
Orthopaedics, rheumatology 7.7 12.0 1.66 1.1 3.7 3.0 0.08 2.7 
ENT, Stomatology 7.7 8.1 1.85 1.1 1.8 1.6 0.07 2.1 
Newborns 7.3 6.1 1.77 1.1 6.1 5.6 0.04 0.9 
Psychiatry, toxicology, intoxication, alcohol 4.8 2.0 0.85 3.7 3.6 4.0 0.03 0.9 
Urology–nephrology 4.7 5.0 1.00 1.4 2.5 2.4 0.14 2.4 
Respiratory medicine 4.1 2.9 0.82 1.9 5.4 5.1 1.26 1.1 
Nervous system 4.0 3.5 0.84 1.7 4.5 4.4 1.14 1.3 
Dermatology 3.5 3.7 0.82 1.4 2.7 2.2 0.06 2.0 
Gynaecology 3.1 4.7 0.70 1.1 3.0 2.7 0.06 1.3 
Endocrinology 2.6 2.5 0.54 1.6 4.2 3.3 0.17 1.7 
Haematology 2.0 2.2 0.24 1.7 4.2 3.7 0.84 1.1 
Cardiology 1.8 1.9 0.41 1.7 4.1 3.5 1.41 1.5 
Ophthalmology 1.3 1.5 0.27 1.4 2.0 1.7 0.00  
HIV 1.3 0.7 0.12 3.3 3.1 2.3 1.15 1.4 
Infectious disease (other than HIV) 1.0 0.7 0.24 1.9 4.5 4.9 1.67 1.3 
Vascular 1.0 1.7 0.22 1.1 4.1 2.6 0.37 2.5 
Vascular catheter 0.8 1.1 0.19 1.6 3.8 3.4 0.39 1.2 
Chemotherapy, radiotherapy, transfusion 0.5 0.6 0.06 1.6 4.3 3.9 0.27 0.9 
Burns 0.21 0.1 0.03 2.6 7.4 6.6 0.74 1.5 
Trauma 0.05 0.1 0.01 1.7 23.9 23.2 4.25 1.1 
Unknown 0.06 0.1 0.02 1.6 6.6 5.6 0.82 0.7 

a: Rate ratio is calculated as the ratio of CMUC rate and non-CMUC rate adjusted for age and sex distributions of the CMUC group

Table 3

Share of stays and hospitalization rates according to age, diagnosis groups and type of health insurance coverage in 2007

Diagnosis group 0–19 years old
 
20–39 years old
 
40–60 years old
 
 CMUC share (%) CMUC crude rate (%) Rate ratioa CMUC share (%) CMUC crude rate (%) Rate ratioa CMUC share (%) CMUC crude rate (%) Rate ratioa 
Obstetrics 1.3 0.72 5.2 36.0 9.38 1.5 1.7 0.86 2.1 
Gastroenterology 0.6 1.61 1.3 6.2 2.50 1.4 5.8 4.88 1.1 
Other reasons 8.0 1.23 1.6 8.1 1.93 2.0 12.0 2.83 1.8 
Orthopaedics, Rheumatology 7.5 0.89 1.1 10.8 1.82 1.1 15.3 2.98 1.0 
ENT, stomatology 19.5 2.46 1.0 6.1 1.49 1.4 3.5 1.16 1.7 
Newborns 25.2 3.90 1.1 0.3      
Psychiatry, Toxicology, Intoxication, alcohol 1.5 0.34 2.2 1.7 0.97 4.2 2.5 1.72 4.4 
Urology–nephrology 5.9 1.23 1.6 3.6 0.64 1.3 5.6 1.06 1.2 
Respiratory medicine 4.3 0.97 1.8 1.5 0.42 2.0 3.1 1.11 2.3 
Nervous system 4.3 0.74 1.4 2.7 0.70 1.8 3.6 1.26 2.0 
Dermatology 3.3 0.56 1.3 3.9 1.00 1.5 3.6 1.08 1.4 
Gynaecology 9.9 0.09 1.3 11.5 1.11 1.1 23.6 1.31 1.0 
Endocrinology 2.4 0.38 1.4 1.7 0.40 1.6 3.1 1.08 1.9 
Haematology 1.9 0.17 1.6 1.0 0.18 1.8 2.5 0.47 1.7 
Cardiology 1.1 0.16 1.4 1.2 0.29 1.6 3.5 1.08 1.8 
Ophthalmology 1.2 0.17 1.1 0.7 0.19 1.7 2.2 0.58 1.6 
HIV 0.0 0.01 5.4 0.6 0.18 4.5 1.2 0.27 2.6 
Infectious disease (other than HIV) 1.4 0.31 1.6 0.4 0.14 2.3 0.5 0.23 2.5 
Vascular 0.1 0.01 1.3 1.1 0.18 1.0 3.1 0.70 1.1 
Vascular catheter 0.1 0.02 1.1 0.3 0.07 1.5 2.3 0.69 1.7 
Chemotherapy, radiotherapy, transfusion 0.3 0.01 1.0 0.3 0.03 1.3 1.1 0.18 1.9 
Burns 0.2 0.05 2.6 0.1 0.02 2.5 0.1 0.02 2.6 
Trauma 0.0 0.01 1.7 0.1 0.02 1.6 0.0 0.02 1.9 
Unknown 0.1 0.01 1.3 0.1 0.02 1.8 0.1 0.02 1.8 
Diagnosis group 0–19 years old
 
20–39 years old
 
40–60 years old
 
 CMUC share (%) CMUC crude rate (%) Rate ratioa CMUC share (%) CMUC crude rate (%) Rate ratioa CMUC share (%) CMUC crude rate (%) Rate ratioa 
Obstetrics 1.3 0.72 5.2 36.0 9.38 1.5 1.7 0.86 2.1 
Gastroenterology 0.6 1.61 1.3 6.2 2.50 1.4 5.8 4.88 1.1 
Other reasons 8.0 1.23 1.6 8.1 1.93 2.0 12.0 2.83 1.8 
Orthopaedics, Rheumatology 7.5 0.89 1.1 10.8 1.82 1.1 15.3 2.98 1.0 
ENT, stomatology 19.5 2.46 1.0 6.1 1.49 1.4 3.5 1.16 1.7 
Newborns 25.2 3.90 1.1 0.3      
Psychiatry, Toxicology, Intoxication, alcohol 1.5 0.34 2.2 1.7 0.97 4.2 2.5 1.72 4.4 
Urology–nephrology 5.9 1.23 1.6 3.6 0.64 1.3 5.6 1.06 1.2 
Respiratory medicine 4.3 0.97 1.8 1.5 0.42 2.0 3.1 1.11 2.3 
Nervous system 4.3 0.74 1.4 2.7 0.70 1.8 3.6 1.26 2.0 
Dermatology 3.3 0.56 1.3 3.9 1.00 1.5 3.6 1.08 1.4 
Gynaecology 9.9 0.09 1.3 11.5 1.11 1.1 23.6 1.31 1.0 
Endocrinology 2.4 0.38 1.4 1.7 0.40 1.6 3.1 1.08 1.9 
Haematology 1.9 0.17 1.6 1.0 0.18 1.8 2.5 0.47 1.7 
Cardiology 1.1 0.16 1.4 1.2 0.29 1.6 3.5 1.08 1.8 
Ophthalmology 1.2 0.17 1.1 0.7 0.19 1.7 2.2 0.58 1.6 
HIV 0.0 0.01 5.4 0.6 0.18 4.5 1.2 0.27 2.6 
Infectious disease (other than HIV) 1.4 0.31 1.6 0.4 0.14 2.3 0.5 0.23 2.5 
Vascular 0.1 0.01 1.3 1.1 0.18 1.0 3.1 0.70 1.1 
Vascular catheter 0.1 0.02 1.1 0.3 0.07 1.5 2.3 0.69 1.7 
Chemotherapy, radiotherapy, transfusion 0.3 0.01 1.0 0.3 0.03 1.3 1.1 0.18 1.9 
Burns 0.2 0.05 2.6 0.1 0.02 2.5 0.1 0.02 2.6 
Trauma 0.0 0.01 1.7 0.1 0.02 1.6 0.0 0.02 1.9 
Unknown 0.1 0.01 1.3 0.1 0.02 1.8 0.1 0.02 1.8 

a: Rate ratio is calculated as the ratio of CMUC rate and non-CMUC rate adjusted for age and sex distributions of the CMUC group

Diagnoses were studied in more detail by classification into subgroups (table 4). CMUC beneficiaries had higher hospitalization rates for gastrointestinal tumours (2.2), lung tumours (2.3), head and neck tumours (3.9), haematological malignancies (1.2) and, as a corollary, palliative care (2.0). Higher hospitalization rates were also observed for female genital tract tumours (1.65), but not for breast cancer (0.8). CMUC beneficiaries received a greater number of radiotherapy sessions (0.06%, 1.6) and chemotherapy (0.18%, 1.5).

Table 4

Main reasons for hospitalization according to diagnosis subgroups and health insurance coverage in 2007

Diagnosis group Diagnosis subgroup CMUC Non-CMUC Rate ratioa 
Crude rate/ 100 000 Standardized rate/ 100 000 
Gastroenterology Alcoholic hepatitis, cirrhosis 53.2 10.0 5.3 
Major gastrointestinal and hepatobiliary disease 51.4 16.6 3.1 
Pancreatic diseases, hepatobiliary system 54.6 18.0 3.0 
Ulcer, gastrointestinal bleeding 41.5 14.3 2.9 
Malignant tumours 11.5 5.3 2.2 
Gastroenteritis and diseases 753.5 457.8 1.7 
Bowel obstruction and partial obstruction 21.4 13.8 1.6 
Orthopaedics, rheumatology Collagen diseases (other than respiratory) 23.6 13.5 1.7 
Bone and joint diseases 19.0 11.0 1.7 
Fractures, sprains, dislocations 108.9 65.3 1.7 
Arthroscopies, biopsies 125.8 183.7 0.7 
Multiple trauma 7.1 3.6 1.7 
Urology–nephrology Renal insufficiency 20.1 7.7 2.6 
Kidney, urinary tract and male genital tract diseases 19.7 9.5 2.1 
Circumcision 373.5 195.9 1.9 
Nervous system Nervous system diseases 33.8 13.5 2.5 
Seizures, epilepsy, headache 315.9 155.7 2.0 
Cranial nerve/spinal cord diseases 33.3 16.8 2.0 
Stroke 41.9 23.6 1.8 
Head injury 215.6 131.8 1.6 
Cardiology Hypertension 20.8 7.9 2.6 
Heart diseases, valvular heart diseases 39.4 15.2 2.6 
Coronary artery disease 25.6 12.6 2.0 
Coronary and vascular diagnostic catheterizations 97.0 57.7 1.7 
Coronary and vascular catheterizations with stenting 66.6 39.7 1.7 
Vascular Major revascularization surgery 18.4 8.0 2.3 
Deep vein thrombosis, vascular disorders 39.0 17.6 2.2 
Respiratory medicine Respiratory tract tumours 19.0 8.3 2.3 
Pulmonary embolism and respiratory distresses 89.0 40.3 2.2 
Respiratory tract infections 154.9 70.8 2.2 
Bronchitis and asthma 377.9 188.3 2.0 
Endoscopies (stay <2 nights) 47.4 29.4 1.6 
ENT, stomatology Malignant tumours 24.3 6.2 3.9 
Endoscopies (stay <2 nights) 38.8 22.8 1.7 
ENT infections 173.9 106.9 1.6 
Gynaecology Genital tract malignant tumours 17.5 10.6 1.7 
Breast malignant tumours 33.5 42.0 0.8 
Obstetrics Termination of pregnancy 1004.8 437.9 2.3 
Post-partum diseases 107.0 49.3 2.2 
Ante-partum diseases 410.0 189.7 2.2 
Caesarean section 495.6 339.5 1.5 
Vaginal deliveries 1934.3 1386.0 1.4 
Haematology Haematology other than malignant diseases 97.5 42.3 2.3 
Blood and haematopoietic organ diseases 13.5 5.9 2.3 
Endocrinology Endocrine, metabolic and nutritional diseases 16.9 5.8 2.9 
Diabetes 185.6 84.0 2.2 
Nutritional or metabolic disorders 109.5 57.9 1.9 
Infectious disease (other than HIV) Infectious and parasitic diseases 31.9 12.9 2.5 
Infectious and parasitic diseases, with severe comorbid conditions 20.7 8.5 2.5 
Septicaemia 13.3 6.3 2.1 
Viral infections 61.0 34.5 1.8 
Fever of unknown origin 13.3 7.7 1.7 
HIV  121.7 36.5 3.3 
Psychiatry, toxicology, intoxication, alcohol Substance abuse and alcoholism 479.9 93.8 5.1 
Neuroses, psychoses 217.4 79.2 2.8 
Other reasons Trauma and harmful effects 13.7 3.3 4.1 
Iatrogenic effects and drug intoxication 443.3 159.0 2.8 
Immediate death 24.3 9.7 2.5 
Trauma, allergies, poisoning, with severe comorbid conditions 13.0 5.3 2.5 
Signs and symptoms 55.4 34.9 2.2 
Immediate transfer 247.6 117.1 2.1 
Palliative care 38.3 19.7 2.0 
Treatment follow-up 55.4 34.9 1.6 
Newborns Neonatal problems 18.2 9.6 1.9 
Birthweight <2000 g 63.4 39.3 1.6 
Ophthalmology Eye diseases 28.5 15.7 1.8 
Major eye surgery 27.5 16.5 1.7 
Cataract 70.0 44.1 1.6 
Dermatology Plastic surgery (including for obesity) 91.1 56.5 1.6 
Burns 24.0 8.3 2.9 
Unknown  15.2 9.4 1.6 
Diagnosis group Diagnosis subgroup CMUC Non-CMUC Rate ratioa 
Crude rate/ 100 000 Standardized rate/ 100 000 
Gastroenterology Alcoholic hepatitis, cirrhosis 53.2 10.0 5.3 
Major gastrointestinal and hepatobiliary disease 51.4 16.6 3.1 
Pancreatic diseases, hepatobiliary system 54.6 18.0 3.0 
Ulcer, gastrointestinal bleeding 41.5 14.3 2.9 
Malignant tumours 11.5 5.3 2.2 
Gastroenteritis and diseases 753.5 457.8 1.7 
Bowel obstruction and partial obstruction 21.4 13.8 1.6 
Orthopaedics, rheumatology Collagen diseases (other than respiratory) 23.6 13.5 1.7 
Bone and joint diseases 19.0 11.0 1.7 
Fractures, sprains, dislocations 108.9 65.3 1.7 
Arthroscopies, biopsies 125.8 183.7 0.7 
Multiple trauma 7.1 3.6 1.7 
Urology–nephrology Renal insufficiency 20.1 7.7 2.6 
Kidney, urinary tract and male genital tract diseases 19.7 9.5 2.1 
Circumcision 373.5 195.9 1.9 
Nervous system Nervous system diseases 33.8 13.5 2.5 
Seizures, epilepsy, headache 315.9 155.7 2.0 
Cranial nerve/spinal cord diseases 33.3 16.8 2.0 
Stroke 41.9 23.6 1.8 
Head injury 215.6 131.8 1.6 
Cardiology Hypertension 20.8 7.9 2.6 
Heart diseases, valvular heart diseases 39.4 15.2 2.6 
Coronary artery disease 25.6 12.6 2.0 
Coronary and vascular diagnostic catheterizations 97.0 57.7 1.7 
Coronary and vascular catheterizations with stenting 66.6 39.7 1.7 
Vascular Major revascularization surgery 18.4 8.0 2.3 
Deep vein thrombosis, vascular disorders 39.0 17.6 2.2 
Respiratory medicine Respiratory tract tumours 19.0 8.3 2.3 
Pulmonary embolism and respiratory distresses 89.0 40.3 2.2 
Respiratory tract infections 154.9 70.8 2.2 
Bronchitis and asthma 377.9 188.3 2.0 
Endoscopies (stay <2 nights) 47.4 29.4 1.6 
ENT, stomatology Malignant tumours 24.3 6.2 3.9 
Endoscopies (stay <2 nights) 38.8 22.8 1.7 
ENT infections 173.9 106.9 1.6 
Gynaecology Genital tract malignant tumours 17.5 10.6 1.7 
Breast malignant tumours 33.5 42.0 0.8 
Obstetrics Termination of pregnancy 1004.8 437.9 2.3 
Post-partum diseases 107.0 49.3 2.2 
Ante-partum diseases 410.0 189.7 2.2 
Caesarean section 495.6 339.5 1.5 
Vaginal deliveries 1934.3 1386.0 1.4 
Haematology Haematology other than malignant diseases 97.5 42.3 2.3 
Blood and haematopoietic organ diseases 13.5 5.9 2.3 
Endocrinology Endocrine, metabolic and nutritional diseases 16.9 5.8 2.9 
Diabetes 185.6 84.0 2.2 
Nutritional or metabolic disorders 109.5 57.9 1.9 
Infectious disease (other than HIV) Infectious and parasitic diseases 31.9 12.9 2.5 
Infectious and parasitic diseases, with severe comorbid conditions 20.7 8.5 2.5 
Septicaemia 13.3 6.3 2.1 
Viral infections 61.0 34.5 1.8 
Fever of unknown origin 13.3 7.7 1.7 
HIV  121.7 36.5 3.3 
Psychiatry, toxicology, intoxication, alcohol Substance abuse and alcoholism 479.9 93.8 5.1 
Neuroses, psychoses 217.4 79.2 2.8 
Other reasons Trauma and harmful effects 13.7 3.3 4.1 
Iatrogenic effects and drug intoxication 443.3 159.0 2.8 
Immediate death 24.3 9.7 2.5 
Trauma, allergies, poisoning, with severe comorbid conditions 13.0 5.3 2.5 
Signs and symptoms 55.4 34.9 2.2 
Immediate transfer 247.6 117.1 2.1 
Palliative care 38.3 19.7 2.0 
Treatment follow-up 55.4 34.9 1.6 
Newborns Neonatal problems 18.2 9.6 1.9 
Birthweight <2000 g 63.4 39.3 1.6 
Ophthalmology Eye diseases 28.5 15.7 1.8 
Major eye surgery 27.5 16.5 1.7 
Cataract 70.0 44.1 1.6 
Dermatology Plastic surgery (including for obesity) 91.1 56.5 1.6 
Burns 24.0 8.3 2.9 
Unknown  15.2 9.4 1.6 

a: Rate ratio is calculated as the ratio of CMUC rate and non-CMUC rate adjusted for age and sex distributions of the CMUC group

Hospitalizations for accidents were also more frequent: burns (2.9), multiple trauma (1.7), ‘fractures, sprains and dislocations’ (1.7), head injuries (1.6) and ‘trauma and harmful effects’ (4.1). In the obstetric field, high hospitalization rates were observed for termination of pregnancy (2.3), vaginal delivery (1.4) or caesarean section (1.5), ante-partum and post-partum diseases (2.1), neonatal problems (1.9) and birthweight <2000 g (1.6).

Hospitalization rates for infection were higher in many groups: ENT and stomatology (1.6), respiratory medicine (2.2), gastroenterology (1.6) and more specifically for the infectious diseases group: infectious and parasitic diseases (2.4), septicaemia (2.1) and viral infections (1.8). The rate ratio was 3.4 for HIV disease.

Hospitalizations for investigations or diagnostic procedures were also more frequent in certain groups: endoscopy in ENT (3.9) and respiratory medicine (1.6), vascular catheterization and coronary artery catheterization with (1.7) or without (1.4) stenting. Hospitalizations for arthroscopy and orthopaedic biopsies were less frequent in the CMUC population (0.7). CMUC beneficiaries also presented higher rates of ‘drug intoxication and iatrogenic effects’ (2.8), ‘substance abuse and alcoholism’ (5.1), alcoholic hepatitis and cirrhosis (5.3), hypertension (2.6), diabetes (2.2), nutritional disorders (1.9), etc.

The hospital mortality rate was 0.61% for CMUC beneficiaries, i.e. 1.8-fold higher than for the control population, in which the adjusted rate was 0.35% (table 1). The hospital mortality rate was higher in men (1.0%, 1.9) than in women (0.36%, 1.6) and increased with age: 0.1% before the age of 19 years (1.3) and 1.9% in the 40–59 year age group (1.8) (table 2). Hospital mortality rates for CMUC beneficiaries were higher in many groups: gastrointestinal (2.8), orthopaedics (2.7), peripheral vascular disease (2.5), urology–nephrology (2.4), ENT and stomatology (2.1), burns (1.5) and cardiology (1.5) (table 2).

Discussion

In 2007, 4.7 million CMUC beneficiaries in France under the age of 60 years and below the poverty threshold presented a 30% excess of hospitalization rates and an 80% excess of hospital mortality. Their hospitalization rates were higher for all age groups studied and for all diagnosis-related groups reported during hospitalization especially those related to cancers, infections, cardiovascular disease and trauma.

More frequent hospitalizations and a longer mean stay were described in this low-income population. An Australian study based on a population of 6.4 million inhabitants with 1.8 million hospital admissions revealed excess hospitalization rates of 24–35% for the quintile of this population with the lowest income.34 A Canadian study on 3433 people reported an excess hospitalization rate for low-income earners of 27% compared with medium income earners and 33% compared with high-income earners.35 These figures are similar to those reported in France, but many factors can differ between countries such as definitions of low income, socio-demographic and epidemiological characteristics of the population, and health care organization. It would be theoretically possible to imagine that free primary and secondary care for these low-income earners allows assessment of the real excess health care needs of this population, which are no longer masked by financial considerations. However, free access to care may predispose to increased hospital visits in a population in which this modality of health care is known to be more frequent, resulting in additional excess consumption. One year after introduction of the CMUC, no marked increase of hospital admissions was observed, as the main impact observed was a slight increase of reimbursements for medicinal products and specialist visits. Apart from this reimbursement aspect, many other factors limiting access to health cares persist and some of these factors are more frequent in low-income populations, such as economic, geographical, social and cultural characteristics, organization of the health care system, interactions with health care professionals. These factors may lead to underestimation of the theoretical hospitalization rate in terms of needs, but also raises the question of potentially avoidable hospital admissions in this population which could generate an excess cost: medically unjustified hospitalizations for social reasons, hospitalizations due to lack of prevention and previous regular health care, late or poorer quality management with more frequent readmissions.36,37 Besides, there is a wide variability of CMUC beneficiaries treated by specialists in primary care according to regions, speciality and specialists engaged in extra billing when compared to those with negotiated fees. This last point is still discussed because it is difficult to make allowances between a choice of the beneficiary and a refusal of care by the specialist.

This study cannot assess optimization and quality of care, but hospital stays for endoscopy in ENT and respiratory medicine, and vascular catheterizations with or without stenting, chemotherapy, radiotherapy and palliative care were more frequent for CMUC beneficiaries. These findings are concordant with the higher hospitalization rates for tumours and cardiovascular diseases, the diseases with a poor prognosis. A study conducted during hospitalization for myocardial infarction demonstrated identical rates of angiography, stenting and secondary prevention 6 months after admission between CMUC beneficiaries and non-CMUC beneficiaries. On the other hand, the frequency of arthroscopies and orthopaedic biopsies were lower among CMUC beneficiaries, who were more frequently hospitalized for trauma and bone diseases, suggesting lower screening rates or less intensive management of more chronic and disabling diseases among CMUC beneficiaries.38,39

The excess hospitalization rates for certain diagnoses revealed by this study in CMUC beneficiaries illustrate the types of diseases associated with low income: gastrointestinal, head and neck, lung and cervical cancers, among others, were associated with more frequent and higher tobacco and alcohol consumption or certain viral infections.14–19 Breast cancer was one of the only diagnoses studied with a lower hospitalization rate among CMUC beneficiaries. A lower incidence and prevalence of breast cancer have already been reported for this type of population.20 A higher frequency of cardiovascular diseases, including hypertension, myocardial infarction and stroke has also been reported among low-income groups, but this study also revealed a higher incidence of pulmonary embolism and deep vein thrombosis, less frequently described as being associated with a lower socio-economic level.21–23 Endocrine and nutritional disorders, such as diabetes and obesity, and chronic renal failure are also known to be more frequent in low-income populations.5,24–25 The same applies to trauma and burns.26,27 Many obstetric diagnoses were also more frequent among CMUC beneficiaries: more frequent vaginal delivery before the age of 20 years, caesarean sections, ante-partum and post-partum diseases, termination of pregnancy, resulting in a higher frequency of neonatal problems and birthweight <2 kg.28–30 More frequent hospitalizations for parasitic and infectious diseases are related to living conditions and imported diseases, especially from Africa, for migrants, who are more frequent among low-income earners and intravenous drug users. Psychiatric disorders, a factor of social vulnerability, have been reported to be more frequent in low-income populations, but the present study may have underestimated psychiatric disorders, as psychiatric hospital databases were not included in the study.31 Some of the diseases described above are associated with certain common or specific risk behaviours and risk factors, as reflected by more frequent hospitalizations for alcoholism, intoxication, substance abuse.

A shorter life expectancy has been reported in low-income populations.4 This has been attributed to more frequent risk factors and risk behaviours and also to absence or delayed screening or diagnosis, decreased access to hospital or office medical care and better quality or more expensive treatments, as well as many other social and economic factors.3 In this study, the high immediate or early mortality rate during hospitalization cannot be correlated with specific diagnoses. This higher mortality was probably due to diagnoses associated with higher and more rapid mortality in this low-income population, such as trauma and cardiovascular disease. These diseases and the higher hospitalization rate for tumours account for the overall excess hospital mortality. These diagnoses correspond to causes of death reported in France to explain the excess mortality observed in low-income groups, but also in other European countries.3,40

One of the strengths of this study is that it was based on all of the very large population of the main French national health insurance scheme, i.e. 80% of the French population in the age group studied and 91% of all CMUC beneficiaries. Though we cannot exclude that populations covered by other health insurance systems might have been treated differently even if they had the same coverage but they are mainly categorized according to their occupation. Comparisons between the different French schemes must be performed when all the other databases will be totally merged in SNIIRAM information system.34 The results observed in this study may be difficult to extrapolate to other countries, as they depend on socio-cultural differences, the prevalence of risk factors and risk behaviour, education, employment, economic level, working and housing conditions, countries of origin of migrants, access to health care and national health insurance coverage. Nevertheless, the main diagnoses reported in excess for this low-income population are similar to those reported by other studies in many other industrialized countries, although the amplitude of excess hospitalization may vary. These diagnoses highlight the importance of deterioration of the state of health in these low-income populations, the diversity of diseases observed in low-income populations, which can be subdivided into many subgroups characterized by different health determinants requiring specific and adapted management. This situation clearly illustrates the need to develop prevention and information which can be facilitated by CMUC, by allowing targeting of prevention and screening actions.

For decision-makers, these results emphasize the major effort required to optimize the medical management of these already sick people but also to act on determinants with a medium- to long-term impact, which can be present from birth. Improved management of certain chronic diseases and detection and correction of certain disorders or disabilities can be a positive factor for improvement of the subject’s socio-economic level. However, preventive, social, economic and behavioural actions must also be promoted.

Conflicts of interest: None declared.

Key points

  • CMUC for people with low-income level was associated with high hospital admission and mortality rates

  • Hospitalization rates for CMUC beneficiaries were greater for all of the 22 major diagnostic categories

  • More frequent diagnosis for CMUC were ‘psychiatry, toxicology and alcohol’, HIV, infectious diseases other than HIV, burns, trauma and female genital tract tumours but not breast tumours (0.8).

  • Hospitalizations for investigations such as endoscopies were also more frequent, as well as stays of <48 h for radiotherapy, chemotherapy and dialysis.

  • In this low-income population with free access to health care, rates were higher for many diseases that are known targets for prevention and screening actions.

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