Wednesday, December 30, 2009

HPST Law continues to create controversy

The Loi Hopital, Patient, Sante et Territoire (HPST) continues to confuse and agitate many stakeholders in the French health system. Le Quotidien du Medecin, a newsletter for physicians, on December 14 featured a brief interview with a representative of the unions of hospital practitioners (INPH), Dr. Rachel Bocher. Dr. Bocher expressed consternation at the inability of hospital workers to get a hearing with the Minister of Health, Roselyne Bachelot and for any further clarification on the role of the new hospital administrators who are seen to have a much more powerful position as the law is implemented. She was especially concerned over how professional development and continuing medical education (CME) will be handled.

The various physician groups represented by INPH and others, including general physicians, are concerned about the management of contracts and the control of continuing education. The HPST law has a very large number of detailed changes included in its text and the application of those sections is in the process of clarification. The change from “Continuing Professional Training” (formation médicale continue) combined with professional practice evaluation (evaluation des pratiques professionelles) to “Continuing Professional Development” (développement professionel continu) is seen to be more than just a change of terminology. There is concern that this will centralize control over physicians and create more of a “state” system of management (etatisation).

Monday, December 28, 2009

Premiums to rise for complementary health insurance

The Mutualités of France, the mutual insurance companies that provide supplementary health insurance for 38 million French people will raise their rates by an average of 5% in 2010. This comes after they assured their customers this past October that rates would go up no more than 3.9%. Their reasons: costs associated with H1N1 and added charges for hospitalizations.

The price rises will come in part from increases in drug charges and coverage of a 2 euro rise in hospital charges.

French Surgery Under Fire?

If you've been in France in recent days you couldn't miss the extensive coverage given to the surgical treatment of Johnny Hallyday. Hallyday, called simply "Johnny" in the French press, is a French phenomenon, an aging rock-star who is the Gallic equivalent of Elvis Presley and Michael Jackson. No matter that some consider him well past his prime and many mock his obvious efforts to maintain his appearance and status as a bad-boy rocker through plastic surgery and a very young wife, Johnny is still a much-beloved if not notorious celebrity in France. When word reached the press in early December that Hallyday was being transported to Cedars-Sinai in Los Angles in a coma due to complications of surgery, questions were immediately raised about the quality of the work done to repair a herniated disc in his spine. Hallyday was originally operated on by the French "Surgeon of the Stars," Stephane Delajoux, then developed an infection while visiting the US. He was then re-operated on.

It seems as if Dr. Delajoux has had a few instances of post-operative infection among his patients and an inquiry into the quality of his care has been announced by the Ordre des Medecins, the French body that licenses physicians and oversees the quality of medical care. Delajoux, for his own part, has complained that he is the victim of a veritable "lynching."

This would be a minor, major-celebrity story were it not for the finger pointing about the quality of surgery in France launched from within and outside that country. Conservative (that's a generous term for the the sites that have touched on this) blogs in the US have taken note that the "socialist" system often pointed to as the best in the world has to send its pop-stars to the US to get their surgery done.

On the French side, no less that the attorney representing the Ordre des Medicins called Dr. Delajoux "without scruples." The blogs and newspapers in that country are having a veritable field day with the controversy comparing the care Michael Jackson received from his physicians with Dr. Delajoux's work--which incidentally has been praised as life-saving for the French actress Charlotte Gainsbourg.

Unfortunately for Dr. Delajoux, all this attention has driven him into hiding after being attacked in the streets of Paris December 11; Johnny's fans are enthusiastic if nothing else.

A larger debate over the quality of surgery in France has been opened by the incident and that discussion is going forward in the press.

Tuesday, December 8, 2009

The Prospects for Reforming Primary Care

Paul Sorum started out as an historian earning a Ph.D. from Harvard and teaching at a major university. After a few years he turned his attention to medicine, getting a medical degree at the University of North Carolina and is now a professor of Professor of Internal Medicine and Pediatrics at Albany Medical College, Albany, NY. He focused on France in his historical work and has subsequently kept up with medicine in France participating in research projects that compare physician practice in France and the US. He recently reviewed the plans for focusing more on primary care in France and offered this commentary.


Comparing my own experiences as a US primary care physician (well described by Timothy Hoff in Practice under Pressure: Primary Care Physicians and Their Medicine in the Twenty-First Century) with those of the French pediatricians whose offices I have visited off and on for over a decade, I am convinced that French physicians are even more likely than US physicians to resist the profound transformation of primary care envisioned by health reformers in France (outlined by Dominque Polton).

First, while all physicians are highly educated professionals who, I can attest, dislike anyone telling them what to do, French physicians are even more independent in their clinical decision making than US physicians. Working within a national health insurance system, they have avoided the onslaught of directives from private and public insurers suffered by US physicians.

Second, French physicians have, I think, less experience than US physicians in collaborating in patient care with other physicians and other health care providers. They are far more likely than US physicians to have solo practices or, if they have an associate, to share office space and a receptionist but not to share patients. One reason is that, in contrast to US physicians, they do not have to integrate their practices into a larger group in order to deal more effectively with multiple insurers. French physicians are also less likely than the Americans to utilize mid-level practitioners, and even nurses, in their offices; pilot projects with paramedicals have only recently been undertaken.

Furthermore, although the French have experimented with “maisons de santé”, these do not appear to me to be anything beyond typical US group practices, i.e., they are not true “medical homes.”

Nonetheless, paradoxically, the French may ultimately have greater success than the Americans in transforming the activities and attitudes of primary care physicians. With centralized political, administrative, and health insurance systems—in spite of repeated efforts at decentralization and regionalization, exemplified by the new Agences Regionales de Sante—the French can change fundamental structures and incentives more easily than can the Americans (if they can withstand the resulting protests and strikes). The government controls the number and composition of the doctors who are trained. The Assurance Maladie decides, in negotiation with unions, the reimbursement for different primary care services. If, as suggested by the HPST law, the Sophia project of “therapeutic education” of diabetics sponsored by the Assurance Maladie and Polton’s lecture cited above, both the ministry and the Assurance Maladie are truly determined to make changes in primary care—and this is, of course, a big 'if'--the attitudes of French primary care physicians will surely also change as they work in the new context.


Thursday, December 3, 2009

Looking at Health Reform in the US

Wendell Potter, who was formerly the head of public relations for CIGNA, has been very visible on the lecture and testimony circuits this year given that he has a lot to say about how US health insurance companies operate. He gave a long interview with a reporter from Le Monde that was published in that paper on November 24th. The page three interview had a headline that spread across the entire page: “Ce lobby ne désarmera pas,” meaning the insurance companies weren’t giving up their fight to protect their right to “put profit before the well being of patients.” Potter went on to say how the foolish claims of Sarah Palin and Michelle Bachman that health reform is socialism are messages that have been developed and audience tested by the insurance companies themselves. He emphasizes the huge investment the insurance companies are making in shaping public opinion about health reform emphasizing that their priority is to protect profits.

The Potter interview is just a part of the fairly extensive coverage the French press is giving to health reform in the United States. The tenor of the coverage is generally objective and is often treated as an opportunity to provide a lesson about how American politics operates. Responses from French readers are a bit less measured: one remarked in a comment on the Le Monde interview that Americans are “…anesthetized by consumerism” and “Don’t deserve Obama.”

A French blogger (CAVEAT EMPTOR) tried to make the point that health reform in the US (“The mother of all Obama’s reforms") affected everyone because it provided a chance to show that market systems and market justice broke down when it came to health care and this could be the wedge that would help temper the problems of capitalism. That perception that capitalism was the root cause of the problems with American health care has been repeated fairly often in commentary in France. But, that type of discussion about the relative benefits of socialism and capitalism is a more relevant question in Europe where the terms have less argumentative freight than here in the US—and there are quite viable socialist parties.

An interesting comment by one blogger focused on the similarity between the US Medicare program and the Secu, or social security system in France which finances health care. The Secu provides health care payments with an administrative cost of 3.5-4% compared to the 20-30% that many say applies to for-profit insurance companies in the US. But then, Medicare claims 2-3% to be their cost of administration. (The French data come from the Report of the “Commission des Comptes” of the Social Security System, Results 2008, Predictions, 2009).