Are complementary health really more expensive than health insurance?

This was one of the major arguments in favor of the “Grande Sécu”. When the High Council for the Future of Health Insurance (Hcaam) released its long-awaited report on January 17 for the improvement of our health system, it imagined a scenario in which Health Insurance saw its perimeter widely extended reimbursement and that of complementary health insurance reduced to a very small portion. With the direct consequence of the disappearance of the 7 billion euros in management fees invoiced each year by insurers and mutuals to their members.

The Court of Auditors recalled that in 2018, this item of expenditure, deemed “particularly costly”, for the first time exceeded that of Social Security: 7.5 billion euros for mutual insurance and 7.2 billion for the mandatory scheme. This figure is all the more surprising given that the flow of reimbursements processed by complementary insurance companies is six times lower. Since 2009, management fees for mutuals have jumped by 46%. And some stand out for their high operating costs, such as MMA, Viasanté or even Macif.

However, the drawing is not so simple, warn the Sapiens Institute and the consulting firm Asterès – in partnership with the complementary Aésio – in their study published in March. First, because the management costs of complementary health insurance cover more actions than health insurance. Social security contributions are, for example, collected by Urssaf from companies and self-employed workers. In addition, the Health Insurance, by nature, does not assume any customer acquisition costs, including the marketing of contracts, the cost of marketing teams and advertising.

A difficult comparison

By focusing only on the costs of contract administration – collection of contributions in particular – the experts believe that the comparison is difficult to maintain. they relied on the social security contributions collected by Urssaf – responsible for this mission on behalf of Health Insurance – in order to assess the cost of recovery. Taking as a basis a management rate of 0.24% of the sums collected, the cost of recovery is estimated at 650 million euros, or 10 euros per insured. On the complementary side, the only part of the recovery is not available. A broader indicator, that of administrative costs as a whole, makes it possible to assert that the costs applied by mutual insurance companies amount to 3 billion euros, or 47 euros per insured.

Only one type of cost is finally comparable according to the experts: that linked to the management of health care costs. And he pleads in favor of mutuals. In 2018, the management of complementary claims cost 1.5 billion euros according to DREES, or 20% of their total management costs, and a cost per insured of 23 euros per year. By way of comparison, for the same year, Social Security spent 7.3 billion euros in claims management costs, or 115 euros per beneficiary.

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Too vague a name

It is also the name “management fees”, considered too general, which is a source of confusion according to the institute. In this pile of money, we find in particular the cost of compliance with regulatory obligations. For several years, mutuals have had to adapt to a slew of reforms that are far from painless financially: 100% health, directive on insurance distribution, termination of contracts at any time… Management costs also include investments in the fight against social fraud – personnel, artificial intelligence, automatic checks – which nevertheless make it possible to “reduce the benefits wrongly paid” and therefore to reduce the contributions for the insured. In the case of dental care, the fight against fraud social allows to divide by 3 the benefits paid after verification, remind the experts of Sapiens.

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