Long-term illnesses and sick leaves: the bold strategies of Health Insurance to control healthcare costs

As the Health Insurance deficit widens at an alarming rate, the need for an in-depth reflection on controlling healthcare costs becomes essential. With an estimated shortfall projected at 16 billion euros for 2025, this deficit could rise to 41 billion euros by 2030, due to demographic aging and the multiplication of chronic conditions. These, known as long-term illnesses (LTI), alone account for a significant part of expenses, covering nearly two-thirds of healthcare charges.

Faced with this situation, the National Health Insurance Fund (Cnam) proposes a series of bold measures through a report submitted to the government and Parliament in June 2025, aiming to reorient Public Health toward better cost management. Among these are actions on prevention, a review of the LTI system, controlling sick leaves, as well as a discussion on reimbursement for thermal cures and other benefits whose effectiveness remains contested.

The stakes are high, both for the insurance of insured individuals and for the financial sustainability of the social security. In a tense context, the balance between quality of care, optimal protection via the third-party payment, and budget constraints must be reassessed. This article explores innovative and sometimes controversial strategies developed to optimize this complex management of long-term condition care and sick leave.

Optimizing the Long-Term Illness System: a Key Challenge for Health Insurance

The system of Long-Term Illnesses (LTI) is an essential pillar of social protection, guaranteeing 100% coverage of care related to serious and chronic pathologies. However, its financial weight is no longer negligible: in 2021, over 13.7 million French people benefited from this status, with expenses nearing 123 billion euros, representing nearly 60% of Health Insurance reimbursements.

The management of this system raises questions about medical coherence and medium-term financial balance. The temptation of structural reform is under consideration, notably to temporarily exclude patients in sustained remission – for example, those recovering from stable cancer – from the LTI framework. This prospect is strongly opposed by patient associations who warn of risks to care quality and a ‘unjustified’ challenge to insured rights.

Strategies for an Effective Overhaul of the LTI System

• 💡 Adaptive temporary exits for remission cases, with the possibility of rapid re-entry in case of relapse.
• 💡 Enhanced medical control and precise assessment of medical coherence to adjust beneficiaries.
• 💡 Strengthening digital tools, notably with the use of personalized platforms like “My Health Space” for optimized monitoring.

International examples show that such adjustments, made with caution, can promote better expense management without severely impacting care pathways, provided medical rigor and transparent communication are maintained.

Aspect 🏥	Current Situation	Envisaged Reforms	Expected Impact 💡
LTI Population	13.7 million insured	Temporary exclusions for remissions	Reduced treatment-related expenses
Medical coherence control	Universal coverage	Strengthened controls	Optimized care without deterioration
Personalized monitoring	“My Health Space” platform deployed	Expansion of targeted prevention services	Lower risk of aggravation

For more information on the LTI system

Enhancing Prevention Policies to Contain Expenses Related to Chronic Diseases

Prevention, recognized as a key lever, introduces new momentum into the cost management strategy of Health Insurance. It is estimated that nearly 40% of cancers could be avoided by modifying certain behaviors such as tobacco or alcohol consumption. Accordingly, emphasis is placed on personalized prevention and promoting healthier behaviors on both individual and collective scales.

Means Implemented for Effective Public Health Prevention

• 🚭 Programs to combat smoking and alcohol dependence in the most affected territories.
• 🍎 Enhanced nutritional consultations and advice within the patient care pathway by general practitioners.
• 📱 Digital tools and platforms to disseminate personalized recommendations via “My Health Space”.
• 🏃 Promotion of regular physical activity and accessible programs, especially for seniors.

These actions aim not only to reduce long-term expenses but also to improve quality of life, thus supporting the national insurance perspective. Results from pilot departments show a clear decrease in hospitalization and sick leave rates linked to these risk factors.

Program 🎯	Target	Resources Used	Observed Results 📈
Anti-smoking efforts	General population aged 18-65	Campaigns, consultations, nicotine substitution	15% reduction in new smokers
Alcohol and dependency	At-risk adults	Support groups, awareness campaigns	10% reduction in alcohol dependency hospitalizations
Physical activity for seniors	Seniors over 60	Tailored exercise programs, workshops in elderly care homes	20% decrease in sick leave due to falls

Read also on the remedies provided by Health Insurance to contain deficits

Revising Sick Leave Rules for Effective Expense Management

Sick leave constitutes another important lever for controlling healthcare expenses. The trend of lengthening and increasing sick leaves results in significant costs for the social security system. In 2025, several experts highlight a drift phenomenon, particularly when the leave is not medically justified but caused by social conflicts or professional difficulties.

Proposed Measures to Manage Sick Leaves

• ⚠️ Mandatory inclusion of reasons for leave and associated durations in medical certificates, for greater transparency and analysis.
• ⚠️ Bonus-malus system for companies based on their absenteeism prevention policies and retention at work.
• ⚠️ Enhanced medical coherence through controls and audits to detect abuses.
• ⚠️ Implementation of specific support for employees in vulnerable situations, ensuring a gradual return to work.

This strategy aims not only to slow down the rising costs associated with daily allowances but also to promote shared responsibility among employers, employees, and general practitioners. Preventive measures to avoid social conflicts are thus key in combating cost inflation.

Measure 🛡️	Description	Objective	Expected Effects 📉
Absence without medical reason	More detailed information required in sick leave certificates	Limit unjustified leaves	15% reduction in non-medical leaves
Bonus-malus for companies	Reward for absenteeism prevention	Encourage preventive policies	Decrease in unjustified short leaves
Increased controls	Audits of doctors and employees	Prevent abuse and fraud	Improved medical coherence

Learn more about managing daily allowances

The Challenge of Optimizing Drug Prescriptions Related to LTIs

One of the most sensitive variables remains the management of medication prescriptions within the framework of long-term illnesses. These treatments constitute a significant part of expenses and are continuously increasing, especially due to aging populations and the complexity of care.

Areas for Improvement and Innovations in Medication Management

• 💊 Prescription optimization through better coordination between general practitioners and specialists, avoiding redundancies and overconsumption.
• 💊 Promotion of generics and compliant substitution to reduce overall costs without compromising care quality.
• 💊 Use of medical coherence tools via decision-support software integrated into care pathways.

These measures are part of a sustainable economy approach, ensuring the continuity of treatments and care quality. They are accompanied by increased vigilance regarding suppliers, medication quality, and the appropriateness of renewals.

Measure 💉	Description	Expected Benefits	Controlled Risks ⚠️
Medical coordination	Improved exchange between general practitioners and specialists	Avoiding duplicates, improving care	Prescription confusion
Generics	Systematic substitution when possible	Reduction in medication costs	Patient acceptance
Decision support	Integrated digital tools in practice	Optimization of treatments	Computer errors

More information on managing prescriptions

Contested Effectiveness of Thermal Cures: A Financially Crucial Debate

Another sensitive issue concerns the management of thermal cures, whose therapeutic effectiveness is frequently questioned. Each year, their cost to the social security amounts to about 200 million euros. Voices, including that of the Court of Auditors, recommend delisting or restricting coverage to only medically necessary cases.

Arguments and Proposals for Reforming Thermal Cure Coverage

• ♨️ Rationalization of indications by reserving coverage for scientifically validated pathologies.
• ♨️ Reduction or removal of reimbursement for non-LTI related cures.
• ♨️ Enhanced information to clinicians and patients about therapeutic alternatives.

This debate illustrates the tension between the desire to contain expenses and the need to respect the right to appropriate coverage, especially in a country where thermal therapy is part of the healthcare landscape.

Criterion ♨️	Current Situation	Proposal	Potential Impact
Coverage	100% for most cures	Limited to validated LTI indications	Economy of about 200 M€
Information	Not well formalized	Strengthen training and awareness	Streamlining prescriptions
Post-cure follow-up	Inconsistent across clinics	Standardization of follow-up procedures	Reduced relapses

Learn more about the bold proposals from Health Insurance

Specific Measures for EHPADs and Necessary Medicalization

EHPADs (Establishments for Dependent Elderly People) are at the heart of several proposals to optimize cost management while ensuring quality care. Currently, 32% of residents visit emergency rooms, with only half hospitalized afterward, indicating potential for medical-economic optimization.

Key Actions to Improve EHPAD Care

• 🏥 Stronger medicalization with increased presence of general practitioners and specialized healthcare staff.
• 🏥 Implementation of mobile teams to intervene and prevent unnecessary hospitalizations.
• 🏥 Ongoing training for teams to better manage chronic conditions and limit emergencies.

These measures help limit costs related to travel and hospital stays, improving both residents’ quality of life and overall budget management.

Initiative 🏥	Current Situation	Objectives	Expected Results 📊
Medicalization of EHPAD	Limited presence of medical staff	Reduce emergency visits	20% decrease in emergencies
Mobile teams	Few deployed	Rapid care on-site	Fewer hospitalizations
Ongoing training	Varies across facilities	Better management of chronic conditions	Overall improvement in care quality

Consult rights and systems related to EHPADs

The Role of Mutual Insurance Companies in Overall Cost Control Strategy

Beyond mandatory Health Insurance, mutual insurance companies play an increasing role in the landscape of insurance. They provide an essential complement to third-party payment and often cover remaining charges related to treatments and consultations for patients with LTIs.

Interactions Between Mutual Companies and Health Insurance for Better Management

• 🤝 Enhanced coordination of reimbursements to avoid overlaps and optimize coverage.
• 🤝 Development of joint prevention programs to streamline care pathways.
• 🤝 Targeted actions for senior populations, including tailored offers addressing chronic needs.

Mutual companies leverage their expertise to support vulnerable insured individuals, notably through information campaigns on the role of general practitioners and managing sick leave. This complementarity is crucial in addressing both economic and human challenges.

Type of Action 🤝	Partnership	Goal	Concrete Example 📌
Coordinated reimbursement	Health Insurance – Mutuals	Reduce remaining charges	Senior Prevention Mutual see here
Preventive programs	Joint actions	Long-term cost reduction	Health plan Ministry of Interior more info
Specific offers for seniors	Mutuals and insurers	Tailored benefits	Senior health mutuals 2025 details here

Digital Technologies and Data for Better Management of LTIs

The use of digital technologies marks a decisive step in controlling healthcare expenses. Integrating medical data through platforms like “My Health Space” allows personalized care pathways. This approach facilitates tailored prevention and early risk detection, thus helping to limit unnecessary spending.

Digital Advances in LTI Management

• 📊 Centralization of medical data for a comprehensive view of health insurance.
• 📊 Decision-support tools for general practitioners, enabling optimization of prescriptions and sick leaves.
• 📊 Personalized monitoring via notifications and tailored reminders for at-risk patients.

These digital tools also promote coordination among healthcare actors and increase shared responsibility in expense management. This digitalization is fully aligned with the modernization of the French healthcare system and can serve as a major lever to contain the deficit.

Tool 📱	Functionality	Benefits	Challenges to Overcome ⚠️
“My Health Space”	Centralized access to personal data	Personalized prevention	Protection of personal data
Decision support	Integrated medical software	Improved care coordination	Professional adoption
Personalized alerts	Patient notifications	Adherence to treatments and appointments	Information overload risks

LTI system and digital innovations

Transparency and Fight Against Fraud: a Leverage to Limit Excessive Spending

Finally, combating fraud is an essential aspect of managing costs related to long-term illnesses and sick leaves. Enhanced controls, increased transparency in medical and administrative practices, as well as enforcement measures are implemented to contain the risk of exceeding the budget.

Mechanisms Established for Transparency

• 🔍 Regular audits of prescriptions and sick leave authorizations with potential risks.
• 🔍 Training and awareness for healthcare professionals on ethics and medical coherence.
• 🔍 Simplified reporting of malpractices or suspicions via dedicated platforms.

These initiatives have helped detect an increase in fraud in certain regions, calling for increased vigilance while ensuring access to legitimate care is not hindered.

Action 🔒	Objective	Results Achieved	Risks Mitigated ⚠️
Targeted audits	Identify abusive prescriptions	10% reduction in abuse	Slowing unwarranted reimbursements
Professional awareness	Improve ethical practices	Better quality of acts	Possible demotivation of professionals
Simplified reporting	Facilitate citizen oversight	More relevant alerts	False positive management

Control of expenses related to long-term illnesses

FAQ – Frequently Asked Questions about Long-Term Illnesses and Sick Leaves

• ❓ What is a long-term illness (LTI)?
  An LTI is a chronic disease requiring prolonged treatment and potentially qualifying for 100% coverage by Health Insurance, such as certain cancers, diabetes, or multiple sclerosis. More information here.
• ❓ How does the management of sick leaves work?
  Sick leaves are prescribed by the primary care physician and entitle, under conditions, to daily allowances paid by Social Security. Proper management is essential to ensure medical coherence while preventing abuse. Learn more.
• ❓ What role does prevention play in cost control?
  Prevention aims to reduce the number of chronic conditions by acting on lifestyle habits and early detection of pathologies, which decreases expenses in the long term. Read about senior prevention.
• ❓ Are thermal cures still reimbursed?
  Reimbursement is currently at 100%, but a revision is under study to limit this reimbursement to validated medical indications, thus controlling costs.
• ❓ How do mutual insurance companies collaborate with Health Insurance?
  Mutuals complement coverage, notably through third-party payment, offer prevention programs, and specialized offers, especially for seniors. See senior mutuals 2025.

Source: www.tf1info.fr