Monday, November 28, 2011

Equality and Solidarity: A Manifesto for the French Health System

A group of senior academics and policy leaders in health released a "Manifesto for Equality and Solidarity in Health" this past September. The Manifesto has attracted a good deal of attention as it was signed by a long list of French opinion leaders and personalities (including a few well known actors). I learned of this during my last trip to France to teach and had the chance to listen to one of its main authors, Didier Tabuteau, discussed the Manifesto at one of the EHESP regular Thursday seminars in Reid Hall where I teach.

I had expected a more impassioned presentation that focused on the justice of an egalitarian health system rather than the recounting of the history of the financing of the health system and the effects of macro-economic trends and realities on its ability to continue to provide services to all but a few in the population.

But the emphasis on the realities of public finance for health care and how it interacts with the larger economy is just the kind of discussion that is occurring in the United States as we begin the understand the limitations of the Medicare system and its finances.

Tabuteau held that the "Secu," the French social security system that is the overall financing vehicle for health services in France, was not doomed to end up in a "hole"(trou). He argued that a continuous adjustment process was necessary to titrate the tax rates that would support healthcare and that titration would rise or fall with the economy.

One point he the authors made make in the Manifesto that he didn't touch on much in the presentation at the EHESP was the "crisis of identity of professionals." According to the authors, doctors and other health care workers are experiencing a "profound malaise" accompanied by a steep decline in their conditions of work; "primary care physicians are living through a crisis that is without precedent" and students choosing to enter the field of medicine are facing hard choices.

The Manifesto speaks of and condemns an "ideology of management" (idéologie gestionnaire) that is affecting prices and costs as "the number of private operators, notably international groups, are investing massively in the health field, seeking to find profits..."

The Manifesto ends with a series of recommendations, primarily to increase reimbursement for care, especially long term care; the "reconstruction of a better payment system (convention) for private doctors; a "re-founding" of the public hospital system and the institution of a "true system of sanitary security and collective prevention."

Sunday, November 13, 2011

French survey reports a long wait for the doctor

Almost 60% of French people surveyed say they have given up going to see a specialist because the delay was too long for an appointment. This result from a poll by the IFOP (Institute Francais d’Opinion Publique) Jalma consulting firm, published in the Journal du Dimanche (JDD) and reported in Figaro, November 13, 2011.

According to those interviewed, it took an average of 103 days to see an ophthalmologist, 51 days a gynecologist, 38 days for a dermatologist, and four weeks for a cardiologist, otolaryngologist, psychiatrist or a rheumatologist.

Getting in to see a specialist in a hospital practice is also hard. A referral to a specialist means a wait of 31 days for a hospital-based cardiologist or 29 days for an office visit; seeing a hospital radiologist takes an average of 21 days or 13 days to see a radiologist in their office.

When the wait seems too long, people choose to go to the emergency room: 27% of respondents say they have used the ER for reasons of time or cost. Up to 58% of respondents say they have given up on at least one appointment with a specialist because of the wait; 33% have done so several times. Some 28% have given up because of geographic distance.

To see a general practitioner, the period is much shorter and is, on average, four days. However, 15% of respondents say they have not made an appointment with a GP because of the distance to the office.

The perception of delays is different depending on whether you ask patients or practitioners. Jalma conducted a parallel survey of 600 doctors who gave different results, reporting much shorter waits.

"There is a big gap between perception and reality for the French. The wait for an appointment described by the doctors are much shorter. This means that practitioners and their patients are not available at the same times," is how Matallah Mathias, president of Jalma, interprets the differences. He suggest that specialists need to adjust their schedules for their patients: "Many will hate this conclusion but specialists must make the change in how they operate to increase access," he argued.

The survey was conducted online from August 29 to September 4, 2011 with responses from a representative sample of 1001 people 18 years or older.

Thursday, November 10, 2011

Indispensable reference work on French health system

A new comprehensive review of the French health system has been published as part of the "Health Systems in Transition" series from the European Observatory on Health Systems and Policies. It can be downloaded as a .pdf at a WHO site. The review is a full 294 pages long and is a very useful reference document for anyone trying to follow health policy in France.

The document was authored by my colleagues at EHESP, Karine Chevreul and Isabele Durand-Zaleski along with Stephane Barhami, Cristina Hernández-Quevedo and Philipa Mladovsky. Dr. Chevreul is the deputy head of the Paris Health Economics and Health Services Research Unit and a researcher in the Public Health Department of the Henri Mondor Teaching Hospital in Créteil and Dr. Durand-Zaleski is the director of those units. Both teach in the EHESP policy modules.

The volume provides a good review of recent policy changes in France that touch on health and health care. The following figure from the book gives a sense of the relative "outputs" of the French health system compared to the OECD average.

Wednesday, October 5, 2011

Continuity of Care/Maisons Medicale de Garde

I have learned that the structure of primary care services in France is very complex and grows in complexity almost daily. As I have said before, primary care is not quite a cohesive concept in France. There is no consensus translation for what we, in the US think is a fairly fundamental component of our health system—no matter that we still argue about it. In France, health policy people are a little uncomfortable when confronting the idea and that may be because they spend more time building the structure of health care delivery than arguing over its principles.

The newest wrinkle I discovered in French ambulatory care delivery is the “Maison Medicale de Garde” (MMG). I encountered this as part of a “jury” assessing a masters paper submitted by a student at the EHESP. Amandine Vial’s paper: “Collaboration between primary care and emergency services: medical home at Ploermel, Britanny,” was a case study of a MMG in the northwest part of France.

The MMG is not completely new, it grew from a general need to maintain continuity of care (permanence des soins) which the French recognized as a challenge in their system. Doctors were “disengaging” themselves from the practice of round-the-clock coverage. Many towns and rural areas simply had nowhere for patients to go after 6 pm and before 9 am except an emergency room. The Descours Report of 2003 called for a system or structure to assure continuity of care “de ville”—meaning, more or less, in the community.

The MMG structure is a cooperative, local agreement among mostly general practitioners and a local hospital to provide coordinated coverage for out-of-hours patients.

Paris has four MMGs, which seems a bit too few for a city of its size. But that’s because there are other options for out of hours care in the capital city. In smaller towns and cities, this may be the only after hours access point.

There is a charge for this kind of care, from 42€ for a weekend visit up to 63€ for evenings. Most French citizens are covered by their mutuelle or eligible for a reduced rate one-third of the full charge.

Continuity of care (permanence des soins) is a concept embedded in French public health law, as Amandine Vial pointed out in her masters paper. It is also a “notion évolutive” or a work in progress. Who is responsible for after hours care remains a controversial subject and some would say that the MMG is a way for some doctors to duck the issue.

Wednesday, September 21, 2011

Keeping in Touch: Making International Partnerships Work

The posts to Santé Carolina have been few in the past months due to some shifts in my work patterns and the end of the Gillings Visiting Professorship. There’s much more to be said about the French health system and I will post more materials in the coming weeks.

I’d like to talk a bit about managing international projects and the difficult process of connecting institutions with different cultures separated by many miles. The EHESP is both a new school of public health but also an established component of the French public health scene. It was deeply embedded in the system of training managers of hospitals and public health structures in France. It’s transformation into the EHESP and its turn toward a more academic direction have not been without problems.

The University of North Carolina’s Gillings School of Global Public Health has also undergone a recent transformation with the change in name and a conscious effort to make itself globally relevant. The UNC school has been connected tightly to the public health structure of North Carolina and the region for many years and served as the primary training grounds for many local and state health directors and program leaders for many years. It has developed over recent decades a strong academic and research enterprise. Some might say that it has replaced its emphasis on community programs with a more detached academic style.

My goal for the Gillings Visiting Professorship was to try to bring these two institutions closer together as I saw interesting parallels between the two. Both institutions were trying to mix a tight connection to the formal, government roles of public health with an academic and research culture. Both had engendered creative solutions to the problems of their health care systems beyond public health and within prevention and public health. And both were stretching to link to global health issues in Africa and Asia.

I also saw how the two institutions were approaching similar challenges in different ways. UNC was pioneering work in leadership training and on-line delivery of classes. The EHESP was organizing teaching in more effective units of instruction—week-long modules and special part-time work spread over a year. UNC was creating new emphasis areas in informatics and data for decision making while the EHESP was organizing focused training in humanitarian program leadership and management and has organized a graduate program that spanned multiple countries in Europe.

Both institutions had much to learn from each other. Unfortunately, that challenge has only partly been taken up. Both institutions must cope with and service their local communities and live with the bounds of their funding and activity constraints. At UNC the budget for the school is strongly party controlled by the North Carolina General Assembly. The state is facing a time of strain in its finances and the legislature has chosen to cut the University’s allocation. This directly affects the school and it absorbed an 18% cut in its state funds. This is a challenge as well as good reason to pay less attention to international work that may distract leaders from the time consuming work on getting to know international partners.

The EGHESP has been challenged by the clash of cultures that emerged when it quickly pivoted toward new masters and doctoral programs, hired in new people and created new programs. The school was moving very quickly and some felt left behind. Its troubles were highlighted by public demonstrations by staff that prompted an external review.

These challenges are transient in the long run and likely to be replaced by others. But the conditions and characteristics of the two institutions that would make them useful partners, remains.

Some strong and persistent connections have been built and there is a continuing flow of faculty and students between the two institutions I will continue to teach in the MPH program in Paris and others will join me as their time is available. We have brought students from he MPH program to Chapel Hill for their practica and that will continue. We have taken doctoral students to share their work with their counterparts in Paris and Rennes and that should continue.

No one can deny the extra effort it takes to work on different continents and the costs of that distance are real. I remain convinced that the effort is worth the pay off.

Friday, April 29, 2011

Ridiculous Stubbornness

France is now going through the process that fixes physician fees under what they call the “convention”. This is a formal negotiation that involves the health insurance system, l’Assurance-Maladie, and the unions, or “syndicats” of physicians. That process hasn’t happened in three years and both sides are itching for an update.

A big issue in US health policy is how physicians are to be paid under the Medicare program. The fee scale for doctors is determined by a complex process that weights each billable activity according to its “relative value.” That process is adjusted annually. But the overall cost to the system from the physician payment component, or Part B, is to be controlled by a global expenditure target that is intended to keep growth in proportion to change in all prices. This “Sustainable Growth Rate” or SGR, has proven to be difficult to apply as its formula has required larger and larger cuts which are resisted by physicians and “fixed” by the US Congress which can override the formula. Because the SGR law stays in place, there is a constant struggle to adjust rates based on negotiations, mostly with physician groups pressing Congress to allow for payment rises.

We have become a little like France in that the process is a continuing dance of negotiation, but the US leaves it to the general political process with Congress acting as the regulator of relatively detailed policy.

For France the issue of physician payment is now tied to problems of “medical desertification” as well as the continuing problem of excessive billing. Geographic maldistribution of doctors, or medical deserts, has risen on the policy agenda of late and there is an interest in creating incentives to entice doctors into rural and urban underserved areas. A group at IRDES (Institute de Rechereche et Documentation d’Economie de la Santé) is exploring how other countries do this in the hope that there are effective mechanisms out there that might help adjust the balance if applied in France.

The negotiations over rates in France hit a glitch earlier this week when the head of the Confederation des Syndicates Medicaux Francais, CSMF, which is supposed to coordinate the negitations among the physician groups, objected to the number and types of negotiators from some of the physician groups. He complained that the Medecins Generalistes and groups representing anesthetists, surgeons and obstetricians brought in “representatives of interns and young physicians into their delegations.”

The House of Medicine in France is becoming fractured the same way as in the US as specialists and generalists, surgeons and physicians, see the process of payment negotiation in different ways.

For the French it looks like the negotiation for the new “convention” will be delayed for “eight to fifteen days while the syndicates figure out a new negotiating group” as the newspaper Figaro put it. The CMSF issued a press release April 27th saying they “find ridiculous the unnecessary stubbornness” of the minority syndicats.

Wednesday, March 30, 2011

Tracking contagious disease in France

The website for Le Quotidien du Medecin included maps showing the distribution of flu cases for the 8th week of 2011. The “surface trend" map gives a sense of the regional prevalence of cases. These maps are updated weekly on "sentiweb"

The web site is a collaboration between general pracitioners and researchers in France

It is made up of a "Réseau Sentinelles," a network of 1300 volunteer primary care physicians “médecins généralistes”, or general practitioners, working throughout the metropolitan regions of France (2% of the total general practitioners in these regions). Its goal is to provide clinical surveillance in France for 10 health indicators. Each member doctor is known as a “médecin Sentinelles” (or “Sentinelles doctor”). The network was created in November 1984 by Professor Alain-Jacques Valleron, and is regulated under the auspices of the research unit "U 707" of INSERM (the French NIH) and the University of Paris VI: Pierre and Marie Curie.

The site also includes a map showing a very high recent prevalence of diarrhea that occurred in the first week of January. Over 580,000 cases were rerported.

Saturday, February 5, 2011

What does a French doctor charge?

In France you can find out exactly what the doctor will charge you by looking them up using Ameli-Direct, a service of the Securité Sociale, Assurances Maladie, the national health insurance system.

You just have to enter the name and location of the doctor and you'll get a page that details their charges. The list won't be very long, as there are only a few options for charges for a generalist and specialists provide a sample of charges for common procedures but it can be very informative.

A general surgeon in Avignon, Dr. Alexandre Llory, specifies his charges for excising a pylonidal cyst, that range from 147,24 € to 153,13 €. Three other procedures are listed for Dr. Llory on the results page. Office visit charges are also listed;hHis normal consultation charge is 40€ but only 23€ are reimbursed by the insurance system.

Bringing Research to the Public

The French Association for Research in Cancer (ARC) commissioned a survey to understand public perceptions of cancer research and researchers. Le Guide Santé reports that three-quarters of respondents feel researchers are the best source for cancer advice about risk and behaviors. The survey found that young people, those under 24, are more interested in than other groups in understanding how cancer affects the body.

The ARC is organizing a “debate” that brings together researchers and opens the floor to questions from the public. Internet users can asked questions at: http://www.grand-direct
This public interaction with the research establishment and the public is “unique to France" according to Brèves Santé, a health oriented web site. Indeed, reaching out this way to link bench scientists to the public is not something seen elsewhere. In the US, there are emerging outreach and “translation” activities that are being promoted by the National Institute of Science (NIH). The Clinical and Translational Science Awards (CTSA) mechanism requires academic health centers to formally structure dissemination and “bench to bedside” linkages.

At UNC, the “University Cancer Research Fund” was created in 2007 by the NC General Assembly to promote research but to also link the research enterprise to communities. The Lineberger Cancer Center at UNC-CH has underwritten a wide range of projects and programs that connect the scientists in Chapel Hill and in community based projects with patients, survivors and the general population.

The outstanding question is whether the NC and US population feels as trusting of cancer researchers as the French. Mark Hall, a professor at Wake Forest University has published a study that describes how to measures public trust in researchers but the scales and methods haven’t been used to assess how Americans feel about biomedical scientists.

Friday, January 14, 2011

Medical Desertification

The French Senate Jan. 13 debated the “demography” of physicians, with a focus on “medical desertification” of rural areas, reports Quotidien du Medecin.

Senator Bernard Vera described the demographic situation as so degraded that it is "essential to restrict the establishment of new practices in areas already provided for."

Vera proposes to draw on the regulatory mechanisms that are now applicable to nurses (nurses cannot go into independent practice in locations that are “sufficiently” supplied). This is controlled by the SROS (Schéma regionale d’organisation sanitaire or regional health plan) which is to be applied by the new regional health authorities (ARS). Many who oppose this say it is “whittling away at the principle of freedom of practice location.”

Vera also proposes to allow specialists in general practice to collect fee supplements that are paid for other specialists. This kind of “bonus” would apply in certain, underserved areas.

Hervé Maurey, Senator from Eure said: "We will not solve the problem of medical demography with force." The program to shift nurses developed in 2008 has shown that coercion does not work. Hervé Maurey recalled that at discussions on the law HPST he had proposed several amendments, including the requirement that all young graduates to go serve three years in undeserved areas. "You will see in five or ten years," he prophesied, “you will see that the HPST law that rejects the social contract for solidarity in health, will have had no effect on medical demography.

For her part, Nora Berra, Secretary of State for Health, said that 200 medical students had already signed a contract for public service, which entitles them to a grant of EUR 1 200 per month until the end their education in exchange for a commitment to practice for an equivalent period in an underserved zone.