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

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

Faced with this reality, the National Health Insurance Fund (Cnam) proposes a series of bold measures through a report submitted to the government and Parliament in June 2025, aimed at redirecting Public Health towards better cost management. These include actions on prevention, a complete overhaul of the LTI system, stricter control of sick leave, and a review of reimbursement for thermal spa treatments and other services whose effectiveness remains debated.

The stakes are high, both for insurance coverage of policyholders and for the financial sustainability of the Safety Net. In a tense context, the balance between quality of care, optimal protection through third-party payment, and budgetary constraints must be reassessed. This article explores innovative and sometimes controversial strategies developed to optimize this complex management of long-term conditions and sick leave.

Optimization of the Long-Term Illness System: a Central Issue for Health Insurance

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

Managing this system raises questions about medical consistency and medium-term financial balance. The temptation of structural reform is under consideration, particularly to temporarily exclude patients in sustained remission — for example, those emerging from stable cancer — from the LTI framework. This perspective is strongly opposed by patient associations, which warn of potential harm to care quality and a “unfair challenge” to insured rights.

Strategies for an Effective Overhaul of the LTI System

• 💡 Temporary tailored exits for remission cases, with the possibility of quick re-entry in case of relapse.
• 💡 Enhanced medical control and precise assessment of medical coherence to adjust beneficiaries.
• 💡 Strengthening digital tools, especially through the use of personalized platforms like “My Health Space” for optimized follow-up.

International examples show that such adjustments, when carried out cautiously, can promote better expense management without severely impacting care pathways, provided medical rigor and transparent communication are combined.

Aspect 🏥	Current Situation	Envisaged Reforms	Expected Impact 💡
LTI Population	13.7 million insured	Temporary exclusions during remission	Reduction of treatment-related expenses
Medical coherence control	Universal coverage	Strengthened controls	Optimization without worsening care quality
Personalized follow-up	“My Health Space” platform deployed	Expansion of targeted prevention services	Reduced risk of deterioration

For more information on the LTI system

Strengthening Prevention Policies to Contain Chronic Disease Expenses

Prevention, regarded as a key lever, brings new momentum to the cost control strategy by the Healthcare Insurance. It is acknowledged that nearly 40% of cancers could be prevented by modifying certain behaviors such as tobacco or alcohol consumption. The focus is on personalized prevention and promoting healthier behaviors at both individual and collective levels.

Tools Implemented for Effective Public Health Prevention

• 🚭 Anti-smoking and alcohol dependence programs in the most affected areas.
• 🍎 Enhanced nutritional consultations and advice integrated into the patient pathway by the primary care physician.
• 📱 Digital tools and platforms to disseminate personalized recommendations on “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, supporting the national insurance coverage goal. Results from pilot departments show a clear decrease in hospitalization and sick leave rates related to these risk factors.

Program 🎯	Target	Resources Engaged	Observed Results 📈
Anti-smoking efforts	General population aged 18-65	Campaigns, consultations, nicotine replacement	15% decrease in new smokers
Alcohol and dependency programs	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 nursing homes	20% decrease in sick leaves due to falls

Read more about the remedies from Health Insurance to contain deficits

Revisiting Sick Leave Rules for Effective Expense Management

Work stoppages are another important lever for controlling healthcare expenses. The trend toward longer and more frequent sick leaves incurs significant costs for the Social Security system. In 2025, several experts highlight a drift phenomenon, particularly when leaves are not strictly medically justified but are due to social conflicts or professional difficulties.

Proposed Devices to Control Sick Leave

• ⚠️ 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 work retention practices.
• ⚠️ Enhanced medical coherence through controls and audits to detect abuse.
• ⚠️ Implementation of specific support for vulnerable employees, ensuring gradual return to work.

This strategy aims not only to slow the growth of expenditure related to daily allowances but also to reinforce shared responsibility among employers, employees, and treating physicians. Prevention of social conflict upstream is thus a key element in fighting cost inflation.

Measure 🛡️	Description	Objective	Expected Effects 📉
Lack of medical reason	More details 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	Reduction of unjustified short leaves
Increased controls	Audits with doctors and employees	Prevent abuse and fraud	Improved medical coherence

Learn more about managing daily allowances

The Challenge of Optimizing Prescriptions for Long-Term Illnesses

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

Avenues for Improvement and Innovation in Medication Management

• 💊 Prescription optimization through better coordination between primary care physicians and specialists, avoiding redundancies and overuse.
• 💊 Promotion of generics and substitution in accordance with guidelines, to reduce overall costs without compromising care quality.
• 💊 Use of medical coherence tools via decision support software integrated into the care pathway.

These measures are part of a sustainable economy approach while ensuring continuity of treatment and quality of care. They are accompanied by increased vigilance over suppliers, medication quality, and the relevance of renewals.

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

More information on prescription management

Questionable Effectiveness of Thermal Spa Treatments: A Financially Critical Debate

Another sensitive topic concerns the management of thermal spa treatments, whose therapeutic effectiveness is frequently questioned. Each year, their cost for the Social Security system reaches approximately 200 million euros. Voices, including that of the Court of Accounts, recommend either ceasing reimbursement or restricting coverage to strictly necessary cases.

Arguments and Proposals for Reforming Coverage for Thermal Spa Treatments

• ♨️ Rationalization of indications by reserving reimbursement for scientifically validated pathologies.
• ♨️ Reduction or even elimination of reimbursement for treatments not related to LTIs.
• ♨️ Enhanced information for primary care physicians and patients about therapeutic alternatives.

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

Criterion ♨️	Current Situation	Proposed Solution	Potential Impact
Coverage	100% for most treatments	Limited to validated LTIs	Saving around €200 million
Information	Poorly formalized	Strengthen training and awareness	Rationalization of prescriptions
Post-treatment follow-up	Inconsistent across establishments	Standardization of follow-ups	Fewer relapses

Learn more about the bold proposals from Health Insurance

Specific Measures Concerning Nursing Homes and the Necessary Medicalization

Nursing homes for dependent elderly people (EHPAD) are at the heart of several proposals aimed at optimizing cost management while ensuring care quality. Currently, 32% of residents visit emergency rooms, with only half being hospitalized afterwards, revealing an opportunity for medical and economic optimization.

Key Actions to Improve Care in EHPAD

• 🏥 Enhanced medicalization with increased presence of primary care doctors and specialized healthcare staff.
• 🏥 Implementation of mobile teams to prevent unnecessary hospitalizations.
• 🏥 Ongoing training of staff to better manage chronic conditions and limit emergencies.

These measures help reduce costs associated with transportation and hospital stays, while improving residents’ quality of life and overall budget management.

Initiative 🏥	Current Situation	Objectives	Expected Results 📊
Medicalization in EHPAD	Limited presence	Reduce emergency visits	20% decrease in emergencies
Mobile teams	Limited deployment	Rapid on-site care	Fewer hospitalizations
Ongoing training	Variation across establishments	Better management of chronic conditions	Overall care improvement

Consult rights and systems related to EHPAD

The Role of Mutual Insurance Companies in the Overall Cost Control Strategy

Beyond compulsory Health Insurance, mutual health insurance companies are playing an increasingly important role in the landscape of insurance. They provide an indispensable supplement to third-party payment and often cover remaining costs related to treatment and consultations for LTIs.

Interactions Between Mutuals and Health Insurance for Better Management

• 🤝 Enhanced coordination of reimbursements to avoid redundancies and optimize coverage.
• 🤝 Development of preventive programs jointly covered to streamline care pathways.
• 🤝 Targeted action on senior populations, especially through specific offers tailored to chronic needs.

Mutual insurance companies mobilize their expertise to support vulnerable insured individuals, notably through information campaigns about the role of primary care physicians and sick leave management. This complementarity is essential to address economic and human challenges.

Type of Action 🤝	Partnership	Purpose	Concrete Example 📌
Coordinated reimbursement	Health Insurance – Mutual companies	Reducing remaining costs	Senior prevention mutual see here
Preventive programs	Joint actions	Reducing long-term costs	Ministry of Internal Affairs health plan more info
Specific senior offers	Mutual and insurers	Adapting benefits	Senior health mutuals 2025 details here

Digital Technologies and Data for Better Management of Long-Term Conditions

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

Digital Advances in Managing LTIs

• 📊 Centralization of medical data for a comprehensive view of health insurance.
• 📊 Decision support tools for primary care physicians, enabling optimization of prescriptions and sick leaves.
• 📊 Personalized follow-up via notifications and reminders tailored to at-risk patients.

These digital tools also promote coordination among healthcare actors and increase shared responsibility in expenditure management. Digitalization aligns with the modernization of the French healthcare system and can be a major lever to contain the deficit.

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

LTI system and digital innovations

Transparency and Combating Fraud: a Key Leverage to Limit Abusive Spending

Finally, fighting fraud is a crucial aspect of controlling costs related to long-term illnesses and sick leave. Enhanced controls, increased transparency of medical and administrative practices, and enforcement measures are implemented to contain the risk of budget overruns.

Mechanisms Implemented to Ensure Transparency

• 🔍 Regular audits of prescriptions and potentially risky sick leaves.
• 🔍 Training and awareness of healthcare professionals on ethics and medical coherence.
• 🔍 Simplified reporting of malfunctions or suspicions via dedicated platforms.

These initiatives have led to detecting increased fraud in certain regions, calling for heightened vigilance while ensuring legitimate access to care is not hindered.

Action 🔒	Goal	Results Achieved	Risks Mitigated ⚠️
Targeted audits	Identify abusive prescriptions	10% reduction in abuse cases	Slower reimbursements for unwarranted claims
Professional awareness campaigns	Improve ethical practices	Better act quality	Professional demotivation
Simplified reporting	Facilitate citizen oversight	Increased relevant alerts	Managing false positives

Controlling expenses related to long-term illnesses

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

• ❓ What is a long-term illness (LTI)?
  An LTI is a chronic disease requiring prolonged treatment and possibly qualifying for 100% coverage by the Health Insurance, such as certain cancers, diabetes, or multiple sclerosis. More info here.
• ❓ How does sick leave coverage work?
  Sick leaves are prescribed by the primary care doctor and entitle, under certain conditions, to daily allowances paid by the social security system. 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 illnesses by acting on lifestyle habits and early detection of pathologies, thereby decreasing long-term expenses. Read about senior prevention.
• ❓ Are thermal spa treatments still reimbursed?
  Reimbursement is currently at 100%, but an overhaul is underway to limit this to medically validated indications to control costs.
• ❓ How do mutuals collaborate with the Health Insurance?
  Mutuals complement coverage, especially through third-party payment, offer prevention programs, and tailored offers, notably for seniors. See senior mutuals 2025.

Source: www.tf1info.fr