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.


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