Monday, March 22, 2010

Historic, Decisive and very American

The French view of the health reform debate is both overly optimistic and acute. Media coverage has been complete and the passage of the bills in the House merited front page treatment—but distinctly under-the-fold as the regional elections which were a near sweep for the socialist party was the big news this weekend. Le Monde calls the House vote an “Historic victory for Barack Obama” while Figaro put the news a bit lower on its web page calling it a “decisive vote” but leaving Americans “skeptical” of a reform that is “less ambitious than anticipated” which leaves the country divided. The Figaro clipsthat were on today's website were dominated by pictures of the opponents.

The response to the Le Monde story ranged from overly generous applause calling Obama a “real President” in comparison to the “product” Nicolas Sarkozy (whose party lost big in the recent elections). Another writer called it a beautiful victory, “but who is going to pay?”

Le Quotidien du Medecin gave the story top billing and was more or less descriptive. They are running a feature case “La santé version USA” that has been posted for the last few weeks. That includes a story about a New York physician who admits to over treating because of his fears of a lawsuit and a recounting of the 100 years of frustrated health reform efforts.

Meanwhile the generalist physicians of France (at least those in selected unions) are threatening to “close” their offices in protest on April 8th. They are objecting to the mandated charges that will accompany any paper claims that are submitted and objecting to a lost of “identity” not a loss of income.

Tuesday, March 2, 2010

Establishing Primary Care in France is a Struggle

A recent report commissioned by three ministries describes the effort to establish a primary care network in France to have “run out of steam.” (le dispositif de premier recours est à bout de soufflé). “An Assessment of Medical Homes and Health Centers and Plans for their Deployment” was released January 19, 2010. The report found that very few general practitioners were trained to do primary care and that there were few elements in the overall system that could support the development of multidisciplinary care offered in medical homes or primary care centers.

The term “primary care” itself is not really recognized in France and there are a number of alternative terms used to describe what it might become. New proposals to develop “medical homes” and ambulatory care centers have struggled to gain traction as the French system does not have the traditions or infrastructures to support group practice involving the coordination of care centered on the patient. The recent HPST law anticipates an emphasis on primary care as one way to improve access in disadvantaged areas. This latest report called for incentives to create primary care structures in the low-income suburbs and rural communities.

The report also called for a more practical and specific description of the “medical homes” and primary care (or its French equivalent) as a “brand” to which professionals will relate. This should be accomplished under the new Agences Regionales de Santé (ARS). A new legal framework is also necessary that allows the roles and missions of each of the collaborative professionals to be understood and accommodated.

Paying for care in these new structure will also require new mechanisms especially to balance the payments to nurses and supporting personnel. Bundled payments and incentive systems need to be developed and, again, the ARS regional agencies for health are to have a role in the payment structure. The new medical homes and centers also should be seen as places where multi- and pluri-disciplinary professionals can be trained.

For the full report see: