Rethinking Reimbursement: France’s Article 51 as a Model for Real-World Innovation
In 2018, France introduced a powerful tool to reshape its health system from within: Article 51 of the Loi de Financement de la Sécurité Sociale (LFSS).
Rather than relying solely on national directives or randomised trials, Article 51 allows bottom-up experimentation in care delivery and financing — supported by real-world evidence, public funding and structured evaluation.
This framework empowers regional health authorities (ARS), clinicians, hospital groups and non-profits to propose pilot projects that test new organisational models — whether it’s integrated care pathways, bundled payments or digital coordination platforms. Crucially, these projects benefit from derogatory funding rules: procedures or services not normally reimbursed by the national system can be covered under temporary authorisation.
How It Works: Governance and Project Life Cycle
Projects are submitted to and evaluated by:
- The Ministry of Health
- The Caisse Nationale d’Assurance Maladie (CNAM)
- The Comité Technique de l’Innovation en Santé (CTIS)
The process includes:
- Letter of intent
- Detailed proposal + cost impact
- External evaluation plan
- Pilot launch with time-limited funding (typically 2–5 years)
- Mid-term and final evaluations
- Decision to generalise, modify, or terminate
Successful projects are eligible for nationwide scale-up, influencing national codes (NGAP, CCAM, T2A), care models, and reimbursement logic.
Article 51 pilots are evaluated not just on clinical outcomes, but on feasibility and operability, care quality and coordination, budgetary impact and sustainability and transferability to other regions. The evaluation model draws on realist methodologies (Launois et al., 2021) — assessing what works, for whom, under what conditions — and embraces real-world evidence (RWE) as a valid scientific currency for innovation.
Traditional reimbursement in France is act-based: providers are paid per procedure (NGAP for doctors, CCAM for hospitals).
Article 51 breaks this mould. Examples of innovative funding under Article 51 include:
- Bundled payments for integrated care pathways
- Flat-rate funding for post-operative follow-up and prevention
- Temporary reimbursement of non-tariffed professionals (e.g., psychomotricians, psychologists)
In the Obepar pilot, all pre- and post-surgical steps for bariatric patients, including nutrition, psychology and physiotherapy, are covered under a single coordination payment. In theSLDD Occitanie pilot, over €1,500 in evaluations per child are reimbursed without out-of-pocket costs, ensuring universal access to neurodevelopmental diagnostics.
Case Study: SLDD Occitanie — Universal Coverage for Children with Learning Disorders
The Parcours de Santé TSLA Occitanie (2020–2025) targets children aged 6–15 with specific learning and developmental disorders (SLDD). It introduces:
- Multidisciplinary assessment by second-tier professionals
- Free access to neuropsychology, occupational therapy, and psychomotricity
- Structured care pathways with follow-up and outcome measurement
- Integration with France’s national digital health plan (Ma Santé 2022)
Over €21 million in funding has been allocated via the Fonds pour l’Innovation du Système de Santé (FISS) and regional health budgets (FIR). Evaluation is conducted by REES France using mixed methods (quantitative KPIs + qualitative surveys).
Why Article 51 Matters for Policy and Innovation
✔ Evidence-Based Policy
Pilots align with Haute Autorité de Santé (HAS) guidelines and generate actionable policy data.
✔ Systemic Innovation
Encourages bottom-up experimentation with HTA-aligned funding and scale-up potential.
✔ Equity and Coverage
Removes financial barriers to care, particularly for non-tariffed services and underserved populations.
✔ Transferable Lessons
Informs future reforms across Europe: bundled payments, capitation models, and integrated digital care.
Key References
- Launois R et al. (2021). Evaluer autrement les parcours Article 51. Ann Pharm Fr. 80(2):131–144.
- Willig T-N et al. (2022). The Organization of Diagnosis, Care and Funding for SLDD. Front Pediatr. 9:652686.
- Journal Officiel. Article 51, Loi de Financement de la Sécurité Sociale pour 2018.
- Haute Autorité de Santé. Guide Parcours TSLA. 2018.