H1N1 in France, A Shaky Start

In France, the vaccination program for the H1N1 influenza virus is just taking off but the program is looking a bit shaky. The government has developed a plan where the next wave of vaccinations will be given to school children. Students and pupils will be served by mobile vaccination units going to the primary and secondary schools starting today. However, parents have the option of agreeing or not agreeing to have their kids get shots. Households with children in school received letters from the Ministry of Health asking if they agreed to the shots, and, if you were to believe the newspapers, many it would appear, are choosing not to. The evidence for this is in “man-and-women-in-the-street” interviews published, for example, in yesterday’s Le Parisien. Five out of the six people who were quoted said they were not going to sign the approval forms saying they didn’t “trust the vaccine.”

That story is in contrast to the scenes at the vaccination centers in Paris reported in today’s Figaro, the demand for vaccination is creating long lines and frustration. “There is total disorganization” complained one patient, described as a diabetic who had tried several times to get a vaccination. The reporting describes long waits, appointment systems breaking down, vaccine deliveries not made and, above all, the staffing appears to be insufficient to meet demand.

The system was structured to depend on volunteers to help administer the vaccine and both their numbers and training are being criticized. This is reported in the general dailies and on television as well as via specialized news outlets like Quotidien du Medicin, a daily newspaper for physicians. In their coverage the failure to involve physicians and their practices early on in the process is cited as one of the failures.

Le Monde is a bit more restrained in its reporting, they are focusing on the numbers: 605,000 vaccinated by the evening of the 21st with 65,000 people coming into the 1,060 centers each day in the last week

The media reporting has become rather negative about the vaccination campaign. It may be that the system is experiencing teething problems in its early days but the ground is being laid for a general sense that the program is not being run well. The coming week will be a real test for the organization of the programs—and the patience of the citizenry.

Grippe Porcine

The H1N1 influenza pandemic was declared in France before the WHO made its formal statement. That willingness to openly confront the potential for a very devastating pandemic has marked France’s reaction to the disease. Warning posters went up and a vigorous public awareness campaign started early in 2009. There seems little concern that any overreaction would cause political harm. In contrast, commentators snipe at the US federal response for embarking on another “swine flu” folly.

This month the general population in France started receiving vaccinations after medical personnel received the first doses in October. The newspaper Figaro called November 12, “D-Day” for vaccinating the general public and carried a picture of the smiling Minister of Health, Roselyn Bachelot getting a jab from a medical worker and declaring herself “not a typanophobe”—a person with an intense fear of getting a shot.

France has prioritized their vaccinations putting three groups at the head of the queue: nursing children under 6 months, healthcare personnel, and “fragile” persons—especially those with respiratory conditions. To serve them, the Ministry has opened 1,000 centers where vaccinations are available. The Ministry also supports a web site “Info’ pandemie grippale” (www.pandemie-grippale.gouv.fr) this site is not unlike the US web site pandemicflu.gov)with a rish array of links and information and advertises a free phone number for people to call in to get further information about influenza in general and the H1N1 in particular. The web site carries the latest “news” which is focused heavily on the Minister’s exhortations as well as descriptions of symptoms, prevention and treatment advice, as well as data on the global situation. A clickable regional map returns information on places to go for H1N1 vaccine. These centers are carefully regionalized and residents of each commune (township) are directed to their local centers. Interestingly, physicians’ offices were not originally included in the vaccination program.

In response to the exclusion of doctors, Professor Antoine Flahault, Dean of the EHESP and an infectious disease specialist, argued in support of several medical groups for opening up the process saying that “The population ought to have a choice” in where to go for a vaccination. On November 18, the Minister announced their inclusion in the program, but they wouldn’t receive vaccine until sometime in December.

Still, the demand for vaccinations in France has been slow in marked contrast to the situation in the US where the delayed build up in the vaccine supply has created long lines of people waiting for their shots or inhaler doses. In France, in the first 12 days that vaccinations have been available, 250,000 people got them according to the ministry of health. According to pandemicflu.gov, the US has “allocated” 49.8 million doses and shipped 44.1 million as of November 18. Actual vaccination number won’t be available for some time.

Despite this extensive campaign, an October survey found that only 17% of the French intended to get a shot when the vaccine became available. This is in contrast to US surveys that indicate up to half the population will get a shot. But the numbers are adding up, today, Reuters is reporting that 56 deaths were attributed to H1N1 in France since the start of the pandemic and 8 in the last two days. This is in sharp contrast to the US where the death toll is estimated to be 3,900 and characterized as “no greater” than the impact from seasonal influenza.

Resistance to vaccination is being reported in both countries but it appears that France is more sensitive to adverse events and has been a bit more public in soliciting information about them. On November 19 the Agence francaise de sécurité sanitaire des produits de santé (www.Afssaps.fr) issued a bulletin describing their adverse events surveillance system. The bulletin indicated that 200,000 doses of PANDEMRIX had been administered to health professionals and 107 persons reported negative indications including pain at injection site, inflammatory reactions, fever, visual difficulties and “flu” syndrome.

The contrast between the US and France appears to be of one nation trying hard to motivate their population to the pandemic and creating a centralized structure to respond in contrast to the larger nation diffusing its efforts but generating a more vigorous demand.

Medical Homes in France. A Demonstration and an Evaluation

The concept of the "Medical Home" has become a central theme in calls for health system reform in the US.  The medical home idea is familiar to anyone who has followed the development of primary care as an organizing concept.  The medical home emphasizes coordinated care and the use of multidisciplinary teams.  Primary care group practice in France has not developed as rapidly as it has in the US and the use of multidisciplinary teams involving practitioners other than physicians has not been readily embraced in the French system.

However, France is facing an emerging problem in access to care for smaller towns and villages as the number of physicians falls compared to the population and the trend to choose practice in urban areas and the south of France exacerbates geographic inequalities.  The reforms anticipated by the HPST law (Hopital, Patient, Santé et Territoire) include a greater emphasis on primary care that makes use of multidisciplinary teams.  Several demonstration projects have been fielded to test these concept in France.  One of them, PROSPERE (Partenariate pluridisciplinaire de recherché sur l'organisation des soins de premiere recours) is evaluating demonstrations of new organizational forms for primary care in selected regions and communities. A recent report described the results of a case-control evaluation of a medical home demonstration in the regions of Burgundy and Franche-Comté.  The medical homes were activated in 2007 and 2008 and their practices compared to other generalist practices in the same service areas for the medical homes.  The study included 35,198 medical home patients treated by 32 general practitioners and 231,021 control group patients treated by 229 generalists.

From the Abstract of the report: "This study confirms that these structures, when compared to the average practice in general medicine, allow better balance between personal life and clinical practice. The medical homes offer other advantages: increased accessibility due to longer opening times, effective cooperation between professionals, particularly between GPs and nurses, and a wide range of health care options. Further, The quality of care for patients with type 2 diabetes appears to be better in the medical homes despite the high heterogeneity of results. At this stage, we cannot conclude that costs are either higher or lower for patients cared for in the medical homes than in regular local practice."

See:
An Exploratory Evaluation of Multidisciplinary Medical Homes in Franche-Comté and Burgundy. by Yann Bourgueil, Marie-Caroline Clement, Pierre-Emmanuel Couralet, Julien Moques, Aurelie Pierre.

The French Health Care System in One Picture.

A "picture" of the French Health Care Delivery System

This "Organigramme" shows how the French health systems works in a very general way and from the point of view of the Haute Autorité de Santé (HAS). A lot of things are missing but it does give a sense of how the really big parts fit together.  The patient is at the center of the structures and that makes good sense.  source: www.ucanss.fr/activites/formation/accessit/organigrammenouvellegouv.pdf

A Lesson from France on Coooperatives?

Today, in Washington, DC, representatives of the Mutualité Francaise are meeting with key health committee staff in Congress and with the White House’s Office of Health Reform to help them understand how non-profit mutual aid associations in France serve to provide complementary health insurance for 38 million people through a system of 823 different aid organizations. Mutualité Francaise is the organizing body that coordinates the work of those many groups, lobbies on their behalf and provides technical and regulatory services. The mutual (mutuelles) are more than just a private adjunct to the central social security structure. They also operate clinics, dentists’ offices, optician offices and clinics, laboratories and pharmacies. They also provide support to health professional groups. Their power and place in the French health system is a product of the history of labor relations and the power of independent organizations in the French political structure.

The mutuelles provide what is generally classed as “assurance maladie complementaire” or complementary health insurance over and above the social security coverage offered by the major insurance organizations, the Caisses d’assurance maladie. The complementary sector, represented by the Union nationale des organisms d’assurance maladie complémentaire (UNOCAM) involves both private health insurance companies and the larger mutuelle component which provides 60% of the complementary coverage. There are lessons to be learned about how not-for-profit organizations can work in a mixed health insurance structure in the US but they will be complicated by the very complex history of the mutuelle movement.

The mutual insurance companies in France, “mutuelles de santé” are a fairly unique institution in that country. They grew up as an extension of working men’s clubs, as mutual aid societies, more centered on salaried employees than mass-labor. Their emergence and role in health reform is chronicled in Paul Dutton’s book, Differential Diagnosis: A Comparative History of Health Care Problems and Solutions in the United States and France. Dutton describes how, in 1930, when a mandatory health insurance law was passed, the mutuelles were given a specific and powerful role in running those entities. The mutuelles included collaborative groups of physicians, especially surgeons but they were not aligned closely with the trade and professional associations of physicians. At roughly the same time in the US non-profit health insurance organizations like Blue Cross and Blue Shield and cooperative health systems were emerging and there was a real opportunity for insurance legislation to be written to favor these groups. That did not happen and the private firms were left with the opportunity to compete and eventually dominate the market.

The mutuelle movement strongly promotes its non-profit values contrasting themselves with private insurance. They bill themselves as a democratic movement and a union of people, not capital, administered by the members themselves. They base their coverage decisions on the experience of the entire group, not on individual risks….

"Les mutuelles mettent en oeuvre la solidarité entre leurs membres. Elles ne procèdent pas à une sélection personnalisée des risques à l'adhésion et elles n'instituent pas des conditions tarifaires personnalisées. La Mutualité développe une action d'intérêt général en favorisant l'accès aux soins de tous et l'amélioration de la protection de l'adhérent." (Analyse comparative du Code de la Mutualité et du Code des assurances. www.mutualite.fr)

How Much Money Do French Doctors Make?

This wouldn’t seem to be such an important question but for the fact that it comes up quite often when people compare the US and the French health care delivery systems. When someone argues that the French system achieves good outcomes for much less the response is often that French physician make so much less money. The oft cited figure for their annual salary is about $50,000 or “one-fourth” what American doctors make. But is that true?

I rummaged through a series of reports on French physician salaries and I found that it’s not so easy to assign an “average” income for physicians but there are some indications that they make a good deal more than the $52,000 annually that Dr. Bonnaud said he made in an interview with T.R. Reid. In January, 2009 the French Inspector General for Social Affairs issued a report on a study of “Remuneration of Hospital Based Physicians and Surgeons.” It was leaked into the press before final publication because the salaries were so high.: “The report lifts the veil on the remuneration of doctors” said toutemasante.com. That’s because it showed hospital based radiotherapists pulling in 686,913 euros in 2007. Surgeons were comparatively less paid but getting 198,766 euros (that’s $299,000 at today’s exchange rate) with internists getting, on average 111,705 euros.

Those numbers are for hospital based physicians and, as is the case in the United States, office based practitioners may make less. The French IG report did compare office based incomes for an earlier year listing the average income for general practitioners in 2005 at 69,521 euros ($104,281). That’s a bit more than the $50,000 that is often cited.

The organization that represents most of the general practitioners in France reported that their “real” average income in 2007 was just over 70,000 euros; this was their “take home” from a total income of 132,949 euros. These are based on their retirement accounts that the physicians hold; their retirement incomes are based on their “taxable” or reported income. That 70,000 euros is worth $105,000 today.; again, a lot more than the numbers we read in the blogs.

The Medical Group Management Association (MGMA) produces a very useful annual survey of physician “compensation” in the United States. For 2006, they report that family physicians in the US made, on average, $171,519; general surgeons $306,115; and diagnostic radiologists $446,517. Clearly, on average, US physicians make more than their French counterparts, but not always more and not 400% of their American counterparts, maybe 1.5 times would be good benchmark for comparison.

Primary care in France - I

Health Affairs, a leading health policy journal in the United States, recently published a report of a study of primary care across 11 nations. The study found both advantages and shortcomings in many countries with the US lagging in insurance coverage and information technology adoption. The study included France in its surveys but, due to some technical problem with the surveying firm (I am told) the response rate from that country was very low, only 7%. The article does report data from France but urges caution in the interpretation due to the survey problems.

France is a bit awkward when it comes to international comparisons that focus on primary care. The nation has excellent health outcome measures and it noted, (if not notorious) for coming out on top in a WHO-sponsored ranking of nations and their health and health systems. However, France ranks low on indices of primary care, falling at the bottom with Belgium, Germany, and the United States (see Starfield, B. Primary Care: Balancing Health Needs, Services and Technology. Oxford, 2008, p. 347.)

The November Health Affairs article summarized the elements of the health systems of 11 countries and described France, under the rubric of “Primary care doctor role and payment” as not having a requirement for people to register and some national incentives for a gatekeeper role for primary care. In reality, France does have a universal requirement for all residents to register with a physician. That law, passed in 2005, created the médecin traitant system and, by 2007, 87% of those eligible had registered with a physician and 99% of those physicians were general practitioners. An analysis of that program was published by IRDES in March of 2009 (Naiditch M. The preferred doctor scheme: A political reading of a French experiment of Gate-keeping. DT no. 22). Despite this attempt to apparently strengthen the French system more toward a primary care orientation, the results of the médecin traitant program are seen to be largely ineffective in coordinating care and re-structuring the system.

France is looking to organize its primary care services more rationally and effectively. The new re-organization plan, “Loi Hopital, Patient, Santé et Territoire” (HPST) for sees a greater emphasis on primary care. The Institute de Recherce et Documentation en Économie de la Santé (IRDES) organized a conference looking at lessons that could be gleaned from other nations. The conference papers are posted on the IRDES web site.

I will have more about the work of IRDES on primary care in future posts.

Watching What You Eat In France

The French Department of Health and National Institute of Prevention and Health Education (INPES) launched a new campaign to limit consumption of fatty, salty or sweet foods, INPE said Monday.

Three 30-second television spots will be aired starting next week. Each features a specific food item that people would not think of as having too much fat, salt or sugar . For example, in one spot, a man adds excess salt to his hard-boiled egg.

These spots are coordinated with print ads that are targeted to celebrity, cooking, and entertainment magazines.

Brochures repeats these themes "limit your intake of sugar even while being a gourmand," "salt: how to limit its consumption" and "fats: know how to choose and reduce their consumption" will be distributed in 300,000 copies in daily papers on 10, 17 and 24 November.

The materials will all point people to the website www.mangerbouger.fr (eat better, move more--manger mieux bouger plus. The website is found on most food advertisements) where a calculator will help “decode the mystery of food" (“machine a decoder les aliments mysterieux” or Madam). The calculator will estimate the levels of fat, salt and sugar for many families of products (cereals, cheeses, ready made meals ...).

The website will also have a postal for health professionals and users can access a video that describes the National Health Nutrition Program (PNNS).

We have seen a number of comparisons of the US and French health care systems.  One knock on the French from those who don't see much value abroad is that their system is in debt.  Indeed, the social security system in France (Secu) is running a deficit. For 2010, the health related deficit will rise to 15 billion euros, up from 10 billion this year.  These deficits have been appearing more often in the recent past and the government feels pressure to address them.

The response comes in the form of "le projet de loi de financement de la Sécurité Sociale" (PLFSS) which attempts to close the gap in revenues and costs by implementing a number of changes in health related prices and payments.  The finance minister called these changes a "modest" reduction in the deficit and it is not expected that they will wipe out all of the gap.

"We were not far from balancing the social security books and now, with the economic (crisis) ... the deficit is taking off again," said Eric Woerth, Minister of Finance on October 1.

"We need to make savings of around 2.2 billion euros to prevent the trend for higher spending from becoming too strong."

These include increasing charges and co-pays.  The hospital co-pay, created in 1983, is to rise from 16 to 18 euros per day.  This is expected to raise 160 million euros.

There will also be a reduction on the reimbursement proportion for pharmaceuticals which are determine dot have "weak" benefits for patients.  That determination is made by the "Haute Autorité de Sante" (HAS).  The savings are estimated at 150 million euros.

There will be a savings as some drugs move into the "generic" category estimated at  200 million euros.

A reduction in the fees paid to radiologists and laboratory practitioners for certain services—saving 240 million.

These will be combined with other controls on the volume of prescriptions by "high rate" practitioners and a reduction in the use of ambulances to transport non-urgent patients.

There are other mechanisms being used to raise taxes, but they are not directly related to the health care system nor are they assigned to reduce the health part of the Secu budget.

The French health system is undergoing a rather big change in its organization.  Throughout the spring and summer of 2009 the Assemblée Nationale debated a complex law, "Hospitals, Patients, Health and Territory" (HPST) that attempts to reorganize the way the health care delivery system and public health are structured.  The new law calls for the creation of a series of Agences Regionale de Sante (ARS) which will take on greater powers than the predecessor hospital regions (ARH). The regional agencies will, in the words of the Minister for Health, Roselyne Bachelot: "organize the delivery of healthcare across their regions from a perspective of improving access to care and the state of health of our fellow citizens."

The law was finalized in October of 2009 after considerable debate and many amendments.  The first concrete step in realizing the ARS structure has been the appointment of 26 "prefigurateur" or "pending" directors of the ARS.  They are charged with making this complex law come to life.  They will be challenged by the structure of the broader system of government of France which gives some overlapping powers to the "prefets" or prefects, who represent the national government at the regional and subregional level.  In France, local government leaders have a role in the  governance of hospitals and public health systems.  There will be an inevitable clash between ARS directors and the prefectural structure.

I will comment more about the implementation of the HPST law over the coming weeks as it anticipates aligning some aspects of the health care delivery system with American institutions, especially in primary care.