This UML sequence diagram maps the observed financial relationships between patients, doctors, pharmacies, social security and medical insurance professionals in the delivery of patient care in France. Patients visit doctors who administer care and advice and prescribe medication or further treatment.
The patient pays the doctor and visits the pharmacy to pick up their medication. The patient pays the pharmacy directly, and the social security reimburses them or the pharmacy directly. The social security refund the patient for the doctor’s visit and any expenditure at the pharmacy.
Patients must register with Social Security, and possess a health card. The health card includes their social security number and other personal details. The doctor will ask for the health-card at a patient visit. The doctor, via an electronic system, records their visit and receives payment from the patient. The patient can expect to be reimbursed almost entirely for their visit, if up-to-date in their social security contributions and possess additional medical insurance
The appointment and medication that the doctor prescribes are subject to regulated tariffs. The tariffs vary according to the type of doctor and whether within regular working hours or on the weekend. Social Security does not reimburse all medication fully, some partially and some not at all.
Additional private insurance
Where the Social Security does not reimburse fully, a patient may expect to be reimbursed by their medical insurance (mutuelle). Medical insurance reimburses most services and medication but limited by the extent of the patient contract.
Pharmacies receive payment upfront, or the social security and medical insurance reimburse them later for medication supplied. It is a requirement therefore to store the patient’s medical insurance details. The pharmacy must forward their invoice to both social security and medical insurance.
In most cases, transactions are automated, but paper forms are still used if there is no pre-agreed electronic handling relationship with the medical insurance company.
The Social Security is composed of several entities, one which handles employees, another which handles independent and freelance people. Sub-classes of the Social Security entity sometimes exist dependent on the professional branch of the patient.
Use case model
This simple UML use case model illustrates the context and principle processes involved in the delivery and payment of healthcare in France.
Medical care is part of everyday life in France. People expect the system to work and it does. Transaction records are detailed. At period end individuals receive detailed summaries of all transactions such that they may calculate reimbursements are still due or not. The system requires high data integrity, reliable transmission and detailed, widely understood and well-communicated processes.
Social Security administrators exert control over the system by authorising or de-authorising medication for reimbursement. Healthcare professionals require health card readers, a computer, management software and internet connection. Some healthcare professionals complain of the administrative nature of the system, but there seems to be no alternative but to ensure that documents and data flow between the actors.
Drug producers excluded
The model excludes pharmaceutical companies who supply medication. Another set of relationships exists to reimburse companies for their deliveries to pharmacies, hospitals and any other medical dispensaries. It also excludes the (costly) medical infrastructure which surrounds the system such as hospitals, equipment suppliers and specialist care.
The model excludes the medical product development cycle which includes additional actors such as politicians who may have a say in the products developed, approved and reimbursed.
We produced this model based on observable characteristics and the assumption that the system functions as observed.