SantéCarolina

Equality and Solidarity: A Manifesto for the French Health System

2011-11-28T15:00:00.000-05:00

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."

French survey reports a long wait for the doctor

2011-11-13T11:02:00.000-05:00

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.

Indispensable reference work on French health system

2011-11-10T18:16:00.000-05:00

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.

Continuity of Care/Maisons Medicale de Garde

2011-10-05T12:19:00.000-04:00

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.

Keeping in Touch: Making International Partnerships Work

2011-09-21T11:26:00.000-04:00

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.

Ridiculous Stubbornness

2011-04-29T02:40:00.001-04:00

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.

Tracking contagious disease in France

2011-03-30T08:18:00.001-04:00

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.

What does a French doctor charge?

2011-02-05T17:49:00.000-05:00

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

2011-02-05T17:06:00.001-05:00

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 -chercheurs.com.
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.

Medical Desertification

2011-01-14T09:01:00.005-05:00

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.

French Higher Education

2010-11-29T17:55:00.000-05:00

A debate in the New York Times takes on French higher education. Basically, many of the writers say that universities in France and the Grands Ecoles as well, are "sclerotic" and unable to spark creativity.

I have replied in a comment:

Higher education is changing in France. There is a trend to greater independence in the universities and the Grands Ecoles. I have helped design and am now teaching in the École des Hautes Études en Santé Publique (EHESP) in new masters degree programs based on the "Anglo-Saxon" model. We are trying to make these programs more applicable to the "real world" where the students will eventually work and we are trying to change the way we teach to reflect the new generation of students and their needs and demands. In October, master teachers from the University of North Carolina Giillings School of Global Public Health met with their French counterparts from the EHESP for a two day intensive seminar on teaching methods. The topics included: the 'wired' student and social media, managing team based learning, and structuring curricula to match the competencies demanded in the workplace. This is just one example of how French institutions of higher learning are recognizing they need to compete more vigorously in a global market. It will take a lot of work to change the patterns of the past, but I see signs that the old order is crumbling. To give an example, on the agenda for the initial organizational meeting to design the master of public health curriculum was the question of which language to use for instruction. I expected a multi-hour debate and a series of polémiques. After no more than 10 minutes, the group of professors, all French, chose English. That, to me, is a strong sign of breaking with the past.

Médecine de Proximité

2010-11-27T04:14:00.001-05:00

The so-called "Hubert Report" was released November 25. This is a study of the future of generalist medicine in France and was commissioned by Nicolas Sarkozy this summer. Hubert is Elisabeth Hubert, a former general practitioner and minister of health. She was essentially asked to come up with a plan to bolster generalist medicine and, indirectly, primary care.

The report focused on expanding he generalist workforce by instituting required clerkships in ambulatory settings. The idea is to involve more office based physicians in training with the hope that this will expose the medical students to the benefits of this form of practice.

There will also be an expansion of the number of slots for an internship year that prepares new doctors for general medicine. They'll still have the opportunity to move on to specialties after the internship, but, again the hope is that many will choose to stick with primary care and community based group practice in general medicine. There is also emphasis on the promotion of multispecialty group practice and the formation of networks of primary caregivers.

The report covers many issues related to the organization of health care in France and the place of independent practitioners (medecins liberaux). President Sarkozy, in his remarks on the release of the report, promised to propose extensive changes in how health care is paid for and structured. He tasked the new Minister of Health, Nora Berra, as well as former minister, Xavier Bertrand and education minister, Valerie Pecresse to forge ahead with reforms to strengthen generalist care and "médecine de proximité", which Google translates as "outreach medicine".

Yann Bourgeuil, head of IRDES, a research center in Paris that has been working on the evaluation of interdisciplinary care and networks of primary care practices commented on the report on France2, one of the main television networks in France. I'll post his interview when the URL is available.

Doctor supply drops in France

2010-11-24T10:02:00.001-05:00

The question of whether there is an impending shortage of doctors in the US is hot topic these days. I have been appointed to the National Health Care Workforce Commission, created by the Affordable Care Act to help resolve this question and develop the appropriate policies to avert problems, if, indeed they are coming. In France, there have been similar concerns because the number of students allowed to moved past the first year of medical school was constrained by the medicus clausus for so long. Several years ago it became apparent that the doctors in practice in France were becoming older and they were not being replaced by new physcians.

Today, Le Quotidien de Médecin confirmed the trend: "193 943 doctors were active in France on January first 2010. (30.9 per 10,000). This is 5,600 less than a year ago." The data come from the demographic atlas of the profession published by the Ordre des Medecins, the licensing body for French physicians. The Atlas pointed out that the average age for doctors in France is now just above 50 years--in a nation where these is a dispute over raising the retirement age from 60. The new doctors coming in are also changing the face of medicine in France, only 8.6% of physicians are in solo private practice (medecins de ville) and the replacement rate for that group is only 30%.

Vademecum for Loi HPST

2010-11-17T12:21:00.000-05:00

The ministry of health has developed a guide to the HPST Law and posted it via their web site.

This is not a short pamphlet, but a 162-page tome with a fair number of footnotes. It is, however, divided up into useful sections that explain some structures and relationships. Of more interest to me than many others is the section on "The relations between hospitals and primary care." Basically, they are asking for more coordination between the inpatient and ambulatory care sectors. "Multidisciplinary Medical Homes" (maisons de santé pluri-professionnelles (MSP)) are seen as one of the players in a coordinated system.

The Vademecum says: "The law entrusts the ARS with the responsibility for the organization and funding of the coordination and continuity of ambulatory care (permanence de soins), as part of a system (enveloppe fermé). To do this, each ARS will seek to develop payments to professionals to leverage their participation and to build specific mechanisms suited to the localities and conditions and to share medical resources at the interdepartmental or regional level, including with the hospital sector.

A Strike! Of Sorts.

2010-09-07T16:05:00.001-04:00

France underwent a sort of general strike today. It disrupted a lot of train traffic but I am told that the Metro in Paris ran fairly smoothly. Elementary schools were hit and there were protests around the nation--but the impact was not overwhelming--you had to read the papers to know it was happening--but I am sure there are some irate visitors who counted on some train, taking somewhere to whom it is a major problem.

Perhaps 200,000 rallied and marched in Paris and up to 2 million nationwide went to some form of "manifestation."

The issue: raising the minimum retirement age to 62. That may seem a bit of an undershot to most Americans as we will soon get a recommendation from the bipartisan committee on the nation's fiscal future headed by Senator Simpson and Erskine Bowes to raise the age for eligibility for full Social Security and Medicare benefits to something above 65.

The health care system in France seemed to be working without interruption today. My friend, a gynecologist, took her bicycle to work instead of trying the busses or Metro. The hospitals I passed seemed to be open and operating and the web site for most medical and health care groups weren't saying much about the strike.

Health benefits are also being examined for austerity moves. Perhaps there will be more strikes in the coming fall.

Re-Open the Radiotherapy Services in Gueret!

2010-09-06T06:59:00.002-04:00

I've just come back from a bike ride through the French countryside. We, a colleague in health services research and his friend, a statistician, set off from Ussel just inside the Départment of the Creuse. By most accounts, the Creuse is the most rural and less developed part of France. It is also a great place to ride a bike and visit small villages. Immediately as we began our ride I saw signs that called for the "Réouverture du service de radiotherapie Gueret!" (Reopen Raditotherapy Service in Geuret). Gueret happens to be the capital of the Creuse and recently, June 30th, the Ministry of Health decided to close the radiotherapy services in its main hospital on the basis of a "low-volume equals low quality" argument.

The region is up in arms. There was not a village I passed through that did not have a banner or sign that called for the re-opening. I was able to pick up a postcard with an appeal to the Minister of Health as I toured the tapestry museum in Aubusson. There had been rallies and letter-writing campaigns and a web site dedicated to the issue. It was the issue of the day for this part of rural France.

Our little group talked about this at length and we discussed the need to assure quality and maintain efficiency; but when I asked about the history of the decision I learned that the policy decisions about services like this were being drive as much by human error and lack of quality control as they were by demand and volume.

France has a record of accidents in radiotherapy that appears to be abnormally poor. There is even an English-language journal article that reports on these. Although the radiotherapy center in Gueret opened as late as October 2006, after there had been several reported incidents, the effects of accidents may have swayed the decision by the Regional Hospital Agency to close the rural service. Accidents with radiotherapy services in Toulouse in that year and again in 2007 heightened concern among policy makers. This came as France was also coping with the very tragic effects of a tainted blood scandal that occurred years earlier (1980s) but was resolved in the mid-90s with very controversial convictions including the former health minister Edmond Herve.

Some involved in the radiotherapy decision feel that closing the service in Gueret is a result of over-caution on the part of the ministry as they wish to avoid another blood-scandal type of outcome. Others see it as a very practical decision given there are only 150 radiotherapy patients who use the service and just one qualified practitioner to operate the service.

What is interesting is the willingness of local general politicians to take up the cause of a medical policy issue and to rally the populace to argue on behalf of access for a largely rural population.

A Snapshot of Surgery in France

2010-08-13T17:33:00.001-04:00

In the last few days I have been working with the leadership of the American College of Surgeons as they develop policies for the surgical workforce and for surgery in the United States. This seemed like a good time to try to compare the surgical workforce in th etwo countries. The latest summary I could find for France is based on a Parliamentary report from last year on the Future of Surgery (l'Avenir de la Chirurgie). Data for the US surgeon supply comes from the American College of Surgeons Health Policy Research Institute.

On 1 January 2007, there were 24,719 surgeons in France plus 575 surgeons working in overseas departments. This included 16,121 private practitioners (some of whom may also work in public institutions) and 8,597 employed in public institutions. The dominant age of French surgeons is between 50 and 54, representing 21.3% of the total. Just under half, 44.9%, of French surgeons are under fifty years and 34% older than 50. (The US had a total of 135,854 surgeons in 2009, 36.6% were older than 55)

Women make up 23.3% of the French surgery workforce (US 21.3%) with the greatest proportion in obstetrics (37.6%) then pediatric surgery (36.4%) and ophthalmology (43%). The US also has the highest proportion in OBG, 47.1%, then general surgery 14.8%)

The regions with the highest proportion to population are Ile-de-France (Paris), Provence-Alpes-Cote d'Azur, and Rhone-Alpes. In the US the highest concentration of surgeons is in the northeast.

Physicians and surgeons in France may choose to practice completely in the private sector or they may split their time between private and public practice.
- 61.6% in private practice (individual firms, groups, health centers, etc.). This includes 6,532 exclusively in private practice and 6,773 who accept both public and private payers.
- 31.1% are in public hospitals with 4,485 acting as full-time surgeons and 1,057 practicing part time. Teaching hospitals include 2,208 employed surgeons. There are 2,624 FTE surgeons on some form of other contract—for specialized populations, research, management or to temporarily fill staff openings or locum tenens.

By early 2019, the current number of hospital surgeons is expected to decline nearly 30% primarily due to expected retirements. The US surgeon supply is expected to fall by 5-10% by 2025 because there is no growth in training programs and retirements will accelerate.

During 2004-7, the vacancy rate for surgeons in all posts has been stable at 18%, and this steady state is accomplished by the hiring of contracting surgeons.
- 6.4% of all surgeons are practicing in private hospitals; 932 of those are salaried and 347 are exclusively in private practice with 51 in PSPH (Private hospitals caring for public sector patients); 896 were private practitioners in mixed public-private practice.
- 0.9% of the total in another type of setting.

The highest proportion of all surgeons in France are in ophthalmology (22.3%), followed by obstetrics and gynecology (20.9%), general surgery (16.8%), and otorhinolaryngology (11.9%). In the US the largest number are in OBG followed by general surgery then orthopedics.

The distribution by specialty will likely evolve due to career choices among young surgeons and needs of the population. Since 2000 in France, there has been a significant growth in numbers of plastic surgeons while general surgery continues to lose numbers. The same applies in the United States but the greatest growth has been in orthopedics.

MRIs in France

2010-06-23T15:27:00.000-04:00

MRIs in France, or the lack of MRIs in France
A new survey reported in Quotidien du Medecin this week reveals that France has one of the lowest rates of access to MRIs in Europe. The chairman of the French Society of Radiology, Jean-Pierre Pruvo called the situation a “scandal” in an interview in November of 2009. There have been some discussions of how the new regional authorities, the Agences Regionale de Santé (ARS) will change that, but little has been done according to the annual survey by Imagerie Santé Avenir (ISA).

That survey showed France has 8.7 MRI units per million inhabitants (543 machines in January 2010) and waiting times for a scan average 35 days, the same wait as in 2004. In contrast, Germany had 20 per million, Norway 25, Iceland 19.3; and Italy, 18.6 per million. The Unites States has 26 per million, the most of any country.

The lack of MRI scanners is threatening to derail the French National Plan for Cancer which calls for a waiting time for scan of no less than 10 days. The waiting times vary widely by region with the Pays-de-la-Loire having the longest at 58 days. The shortest waits are in Picardie (22.3 days)

The arguments for expanding the supply of MRI units rests on the grounds of cost reductions. Dr. Pruvo cited several examples of more costly surgery and invasive procedures to resolve diagnoses and initiate treatment.

The concern in the US has been with the overuse of MRIs and CT scanners. A recent NEJM article (Michael S. Lauer, NEJM August 27, 2009) estimated that up to 4 million Americans were receiving doses of radiation that were likely to cause cancer.

Who's Striking Today

2010-06-10T10:29:00.000-04:00

In France strikes are a regular thing. Sometimes causing misery but mostly it’s a focused group of raucous people chanting in front of some administration building making their claim for more money or more time off. What may seem unusual to an American is the regular participation of healthcare workers in strikes

This past month we’ve seen a variation on the theme as nurse anesthetists wearing full operating room garb sat on the railway tracks just outside the Gare Montparnasse, blocking all the trains headed west from Paris or into the city from Brittany. Their complaint was over proposed changes to the retirement age, from age 60 to 61 or 62. The vague proposal was part of President Sarkozy’s response to the need for fiscal belt-tightening.

Generalist physician announced their intent to close their offices on June 18 to “educate the local elected officials” about their need to raise their consultation fee from 22 to 23 euros. “We will not wait any longer,” said the secretary general of the Medecins Generalistes-France, Vincent Rebeille-Borgella.

Doctors going on strike is virtually unheard of in the United States and it is generally illegal with a few exceptions. But in France it is something of a tradition. For example, in January 2020 there was the “Day Without Doctors” where three-quarters of all office based physicians stayed home.

Policy-Management Convergence

2010-05-25T15:04:00.001-04:00

I've just returned from another week of lectures and sessions with the 1st Year MPH students. The sessions are all day long from Wednesday until Friday and feature a mix of both policy and management. This last week I focused on planning and evaluation for the management side and health reform for the policy part. My French (British and German) colleagues talked about health reform in Europe while I covered the recent US reform process.

It is clear that the health care systems in the US, UK, France and Germany are very different but they have become more different in the recent past than when they started. The German system essentially set the tone for a social insurance based welfare and health system in the 19th century. This was followed only partially by France and Britain and only partly by the US when Social Security was established in the 1930s.

The lecturers all agreed that World War II was a key turning point for health care systems as the European governments were forced by their electorates to respond to the sacrifices they had made during the war. There was a need to reward long-suffering populations with something tangible after either an exhausting victory, a crushing defeat or a humiliating occupation. Food, housing and a revived economy were hard to produce, but a subsidy for health care drawing on the services of physicians and nurses equally caught up in the aftermath of war was well within reach of the governments.

The US, on the other hand, had been the winner and there was no need to reward the population except to make economic recovery fueled by international commercial expansion as "efficient" as possible. The American answer was to allow a tax-exemption for health insurance benefits to propel a new health insurance industry into a major economic actor. The expansion of their market was abetted by the advances in medical science that were also a product of wartime research and innovation--they made medical care more effective and more valuable.

Europe was launched on a road to an expanded post-war welfare state while the US was resisting any form of government sponsored health care system. The economics of medical care as much as the impulse for social justice prompted the US Congress to provide subsidies for specific populations under Medicaid and Medicaid. Meanwhile Europe just absorbed higher costs and greater use into their social insurance structures bumping taxes up slightly behind the costs of these systems.

But all that rises must converge and the common pattern of inflation of medical costs has started to cause alarm on both sides of the Atlantic. The US was the first to react with technical fixes to constrain use and thereby costs. Europe belatedly shadowed the use of DRGs, RvUs and other market adjusting mechanisms when the systems were only slightly falling behind budgets.

Budgets are now under huge pressure in all 4 countries. The fiscal crisis is showing how luxurious the European welfare system is when populations are aging and the cost and value of medical care are rising more rapidly. So now all four nations are looking at each other to find the best ways to control costs. They are converging more rapidly than they fell apart after WWII. They all share a common task of restraining or curtailing costs expansion without reducing coverage.

This is both a policy and a management task because the politics of budgets can only do so much to change behavior and it is behavior that is at the heart of health care costs inflation. This is the behavior of the system, patients, and its professionals. We simply have to manage behavior better

The real convergence is in the management of systems and how we teach the managers. They are now being forced to make costs containment a priority job, putting access, even efficiency, in trailing places.

More about how that is being taught in the next post.

Cosmetic Surgery in France--A Shift in Emphasis for Women

2010-04-22T12:08:00.000-04:00

According to a survey done by IFOP for the newspaper le Parisien late last year, 14% of women reported that they have used esthetic medicine or esthetic surgery for significant procedures. This is up from 6% in 2002. Younger women account for the fastest growth in use of esthetic medicine; 9% of females 18-24 reported they had already had at least one procedure.

The most common surgical interventions are breast enhancement (19% of those reporting a procedure). Wrinkle treatments are second, (18%), followed by “remodelisation of the thighs and/or buttocks via liposuction" which comes in third (13%). This is s shift from 2002 when the most common surgical procedures were hair-removal, nose reshaping and belly reduction. Breast enhancement surgery was reported only rarely 7 years ago.

Most of the French women, 64% of those responding who have had this surgery, say they do this for their own confidence with only 6% saying they did this to please their partner. This, again, represents a change from 2002 when 21% of women said it was for their significant other.

These kinds of medical treatments are not covered by the French health national insurance system and the cost of the work can be significant. For wrinkle injections the charges are between 380€ and 650€ ($490-$610) depending on the parts of the body being treated. A breast augmentation will cost between $4,000 and $5,000 with a “lifting” of the buttocks up to $14,000. The only cases the state insruance will cover are reconstruction of the breast(s) after cancer treatment.

Patients’ Rights in France

2010-04-15T16:22:00.001-04:00

There is an emerging movement to promote patients’ rights and the French Ministry of Health is promoting best practices through a recognition system. The University Hospital of Brest won the “Jury Prize for the work of its ethics committee in developing a mechanism for counseling patients making them aware of advance directives and applying them in all the units of the hospital. The National Union of Association of Parents of Children with Cancer (UNAPECLE) which held a national stakeholder conference to discuss the challenges faced by children and adolescents with cancer. The program included a series of debates involving parents and peers along with caregivers.

A national law outlining patients’ rights was passed in 2002 with three major goals:

To develop a “sanitary democracy” recognizing the rights for all persons in their relations with the health system by instilling the rights of the users as they relate to the health system and creating consistent national and regional policies.
To improve the quality of the health care system by improving the skills of all practitioners, medical training and prevention policy.
To reduce the risk of illness by improving access to health insurance and establishing a system of medical liability that allows for compensation for victims of medical accidents.

I will describe some of the details of this law and its implementation in greater detail, but one section, the last, stands out. Article 61 Creates a presumption of “imputability” for infections of blood by hepatitis C during blood infusions. This is a further response to the tainted blood scandal of the 1980s and 1990s that resulted in a conviction of a former health minister, Edmond Herve of manslaughter in 1999. He received no sentence.

Historic, Decisive and very American

2010-03-22T14:39:00.000-04:00

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.

Establishing Primary Care in France is a Struggle

2010-03-02T12:06:00.000-05:00

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: www.sante-jeunesse-sports.gouv.fr/IMG/pdf/rapport_maison_de_sante.pdf

Baby Steps to EHRs in France

2010-02-24T11:55:00.000-05:00

France has decided to move completely toward electronic health records—and has committed to universal adoption of a “dossier médical personnel” (DMP). But before that can be done, the system has to get to where all bills are submitted electronically. In September, it was announced that a fine of up to 1 euro would be charged for every paper claim. The principle of this fine system was part of the new law: “Hospital, Patients, Santé, Territoires” (HPST), passed last summer.

In 2008, in France, 86% of clinical offices able to transmit claims transmit electronically but insurers received more than 150 million paper claims. Among physicians, nearly 20% of GPs and over 42% of specialists still used paper claims in 2008. The Mutalités (insurance companies) estimate that a paper claims costs over $2.40 to process while an electronic claim costs only 36 cents.

The fine system didn’t get implemented as planned and there are reports that it will happen this coming May and the fine will be only 50 euro cents.

Setting The Limit on Doctors in Training at 7,400 per year

2010-02-02T12:21:00.000-05:00

France limits the number of students who are trained in medicine via the numerus clausus. This is a restriction on the number of students who are allowed to pass from the initial year of medical training into the 2nd year. Essentially, the top scorers on the end of year examination are allowed to move ahead.

The limit is set by the ministries of higher education and research health and sport and is set each year around this time. The official notice gets posted on "Legifrance" which posts all official decrees and order. The order for the numerus clausus was released January 21, 2010.

By Order of the Minister of Higher Education and Research and the Minister of Health and Sport dated January 21, 2010, the number of first year students of undergraduate medical studies allowed to continue their studies medicine at the termination of the courses following the tests of the academic year 2009-2010 is set at 7 400, divided between the following institutions.....

The 37 medical schools are then listed with their quotas. These range from 550 (Lille-combined universities) to 8 in New Caledonia and 23 in Corsica.

The ministries pay close attention to the numerus clausus as a mechanism for adjusting overall physician supply--an issue that came to the fore in the recent past as it was apparent that France was going to see a decline in overall number of practicing doctors.

The Observatoire National de la Démographie des Professions de Santé (ONDPS) was established in 2003 to monitor supply and needs for physicians. It strongly supported expanding the training pool.

The numerus clausus fell from a high of 8588 in 1971 to a low of 3500 in 1992. Since then it rose slowly through 2001 to 4100 but, on the heels of several predictions of a doctor shortage, has risen rapidly to the 7,400 level This is slightly less than the 8,000 that was predicted a few years ago as necessary to keep the supply in line with population growth and physician retirement patterns.

EHESP Joins with Other Institutions to Create a Research Consortium

2010-02-02T11:39:00.000-05:00

In France there is a relatively unique approach to coordinating research and graduate education through a series of center for research and higher education, or “Poles de recherché et d’enseignement supérieur” (PRES). This mechanism was created in 2006 by the “Pacte sur la Recherche” and was intended to facilitate the process of decentralization in the research and academic community. This is part of a larger trend toward institutional autonomy promoted by the current government. Valerie Pecresse, French Minister of Higher Education and Research, described it this way in 2009:

The development of these centers of research and higher education naturally accompanies the gradual accession of our universities toward autonomy. In these centers, all of the actors in research and education can cooperate and unite their diverse forces to meet their common goals.

Since 2007, 16 PRES have emerged with the most recent being the Université Paris Cité – EHESP, Rennes the latest to organize. This consortium was approved in December and has 7 founding members:
EHESP, (École des Hautes Études en Santé Publique)
New Sorbonne University (Paris 3) www.univ-paris3.fr/
Paris Descartes (Paris 5) www.univ-paris5.fr/
Paris Diderot (Paris 7) www.univ-paris-diderot.fr/
Sciences Po www.sciences-po.fr
Inalco www.inalco.fr/
Institut Physique du Globe de Paris www.ipgp.fr/
Paris North University (Paris 13) (associate member) www.univ-paris13.fr

A summary of the programs and its aims is posted on the EHESP website in English (www.ehesp.fr/universite-paris-cite/). This structure will allow for more cross-disciplinary work in public health and allow students and investigators in a wide range of institutions to work jointly on projects.

"Permanenciers"—The People on the Phone

2010-01-06T15:56:00.000-05:00

In December I was teaching in Paris with a colleague from Chapel Hill. We met prior to the start of his class first thing one morning and he was a little shaky; he reported he hadn’t gotten much sleep and was feeling a bit woozy. “I’ll shake it off,” he said and went into the classroom. I went back downstairs to my office to work and in 30 or so minutes one of the students came in to say that the professor was probably sick and could I come and help.

I went up to the classroom and sure enough, my friend was looking decidedly green and was conspicuously sweating but his skin was cool to the touch. We led him downstairs to a quiet place to sit and gave him water. The students, several of whom were trained physicians or caregivers, were doing some informal diagnosing. One of the young ladies who was in active practice asked for a classmate to go round to the local pharmacy and get a stethoscope and a blood pressure monitor and began to ask questions. “Did you eat? Do you have any pain? When did this start? Do you have a history of coronary disease?” There were some symptoms that fit with a myocardial infarction but no typical pain. The diagnostic equipment arrived, on loan from the pharmacy. His heart sounds were more or less normal but his pulse was rapid. The electronic blood pressure gauge showed a fairly normal 130-90 but the sweating, wooziness and nausea were not abating.

The question was, what to do? Go to a hospital that might be friendly to an American. The American Hospital in Neuilly was mentioned but how to get him there? Was there enough reason to call for an ambulance? The decision was made to dial “15” and contact SAMU, Service d’Aide Medicale Urgente. This connected us to one of the 100-plus call centers in France that handle medical emergencies.

The student/physicians were discussing the situation with the call center and soon were apparently discussing the case with a physician and talking about options. One was to have a “S.O.S. Medecins” or “SOS Doctors” come by. Given the symptoms and the apparent non-emergent nature of the case, that might seem reasonable. After a bit more discussion and some additional checking and more questions, the decision was made to pass that up but to take my colleague by taxi to his hotel where he would be met by an on call physician.

How this was being negotiated was hard to understand but I was told that a “dossier” had been set up for the patient, that if there were any problems or the symptoms became more urgent that I was to call “15” and that they’d be able to connect to his file by name. Further, that a doctor was assigned to the case and available by phone and that we were to go ahead on and the circulating physician would appear at the hotel within the hour.

We got to the hotel and not long after getting the patient into his bed, the call came up from reception that the doctor had arrived. He came up and with dispatch, quickly and expertly interviewed my colleague, checked heart sounds, palpated, and checked eyes and ears.. The discussion was all in English and the doctor was not looking too alarmed nor disturbed. After 15 minutes or so, he opined that it was likely an intestinal infection and that it was “all over Paris” at the time. He offered a few small pills, instructing the patient to take two now and another in an hour and wrote a prescription for more of the same plus an additional drug in case there were bowel problems. When the session was over the doctor took out a small pad and wrote up a bill on a form that was intended to be used for insurance claims. The visit was a “cash-only” affair and the total charge came to 90 euros.

What we had undergone was an interaction with the integrated emergency and urgent care system in France that makes use of a system of communications centers, traveling physicians and various levels of ambulances and patient transportation systems. I knew a bit about this but was fascinated by the fact that a “dossier” had been created and that we could easily refer to that for additional medical care during this episode.

It was not until just before New Years that I got a better idea of what was happening when I read about a series of local strikes of what were called “Permanenciers Assistants de Regulation Medicale” (PARM). When I tried to find out what they were I uncovered a bit of the background to the process we underwent two weeks earlier. The permanenciers (hard to translate, but call them “agents”) were communications specialists who manned the call centers. They are trained in medical triage and are the first line of communication for the rather complex SAMU system. The permanenciers are backed up by physicians who also staff the call centers and who remotely diagnose or refer and make transportation or treatment decisions over the telephone. They are assigned to a case (a dossier is opened) and stick with it until resolution.

In our case, we had the option of having a SOS Medecin come to us. These are physicians who literally cruise the streets of Paris and other cities (or are on call) and make necessary house calls. There are other physician who are ready to attend to less urgent cases, as ours was, with a house call. They function more or less independently but have the ability to motivate a more complex trauma or emergency care system.

But, back to the permanenciers. These key functionaries were striking to get recognition as a specialized and professional cadre of workers as well as a bit of a pay raise. The rolling local strikes seem to have settled down by the first week of January but no resolution to their requests has been reported.

HPST Law continues to create controversy

2009-12-30T16:25:00.000-05:00

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).

Premiums to rise for complementary health insurance

2009-12-28T17:28:00.000-05:00

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?

2009-12-28T13:28:00.000-05:00

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.

The Prospects for Reforming Primary Care

2009-12-08T08:55:00.000-05:00

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.

....

Looking at Health Reform in the US

2009-12-03T15:14:00.000-05:00

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).

H1N1 in France, A Shaky Start

2009-11-25T04:25:00.001-05:00

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

2009-11-20T13:54:00.002-05:00

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

2009-11-13T11:36:00.003-05:00

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.

2009-11-12T14:08:00.003-05:00

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?

2009-11-11T12:14:00.001-05:00

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?

2009-11-10T13:37:00.001-05:00

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

2009-11-06T09:54:00.000-05:00

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.

2009-11-04T18:03:00.003-05:00

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).

2009-11-04T15:24:00.000-05:00

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.

2009-11-03T10:28:00.001-05:00

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.

Financing Medical Care in France

2009-10-01T13:30:00.002-04:00

The US is going through a spirited debate about health reform that is focused mainly on how to finance medical care. France has developed, over time, a social insurance system that covers virtually the entire population for most medical care expense. The comparisons that have been made to the US range from very laudatory (Michael Moore) to critical and negative (Michael Tanner). T. R. Reid’s recently released book, The Health of America” gives praise to the French and other systems, contrasting them with the non-system in the United States. Senator Kent Conrad has recently commented positively about the French system as noted by Ezra Klein. Reactions to praise for government-sponsored health insurance systems have focused on the potential for rationing or the threats to individual freedom. When France is cited as having better health outcomes, critics make use of a controversial statistical analysis that sys that US mortality would equal that of France if deaths from injuries and violence were taken from the numerator..

The French medical care system is supported by the overall Social Security structure, popularly called “Secu” for “Sécurité Sociale”. Health care in France consumes 11.2% of the national income making it one of the most expensive systems in Europe, lagging only behind Switzerland. The overall financing for health care in generally included under a structure called l’assurance maladie, or sickness insurance. This is a social insurance system, often called a Bismark form of financing for health care. Prior to 1945 and the creation of the overall Secu system, mutuelles, or mutual insurance companies provided coverage to employed or self-paying people. They have since developed alongside the national system providing a supplemental private option for French citizens and legal residents.

According to the Ministry of Health report released in September 2009 the overall costs of health care in France in 2008 rose to 215 billion euros or 11% of the GDP; the costs of direct care (consommation de soins et de biens medicaux) accounted for 170.5 billion euros, 8.7% of GDP. The annual growth rates of these two indices, 3.8% and 4.4% were faster than overall GDP growth of 0.7% in 2008 following a 2.1% growth in 2007. The Secu covered 75.%% of the costs of care with complementary insurance covering 13.7% and out of pocket payments, 9.4%. The French government is concerned with the pace of growth of costs but sees the rate as slowing to a plateau after a very rapid rise in 2000-2004. Financing and structural reforms are anticipated to keep cost growth in line with revenues.

The health insurance structure covers 99% of the population through three different schemes: the first includes people employed in commerce and industry and their families (84% of the total), the second covers workers in agriculture and their families (7.2%) and third and smallest covers the self employed (5%)—the remainder covered by the “Couverture Maladie Universelle” CMU. The largest of the insurance organizations is called Caisse Nationale d’Assurance Maladie des Travailleurs Salaries (CNAMTS) and it functions as a combination health insurance company, planning agency, and policy making body; the other two follow suit. The CMU was instituted in 1999 to extend benefits from the statutory system to all French citizens and legal residents, regardless of their employment status. In 2004, coverage was further extended to dependent elderly people through a special fund established for this purpose.

The supplementary plans are like American voluntary, private plans and are purchased by individuals, usually from non-profit “mutuelles” (60%) or from for-profit insurance firms (40%). Typically, this voluntary insurance is meant to cover the portion of medical expenses not covered by the statutory plan or any co-insurance or co-pays associated with care – similar to the “medi-gap” plans in the US for Medicare. In 2000, 43% of those with voluntary coverage subscribed independently, but the rest of the population received coverage from their employer similar to ESI in the United States.

France’s National Health Insurance system is funded by employer payroll taxes (51.1%) and a “general social contribution” (34.6%) levied by the French treasury on all earnings, including investment income. In recent years government anticipated losses in the system and has expanded payroll taxes on employees, instituted special taxes on automobiles, tobacco and alcohol, added a specific tax on the pharmaceutical industry , and shifted funds to provide subsidies to programs or sectors. The budget for the health system remains a problem as expenses outpace revenues.

2009-09-26T07:27:00.000-04:00

This blog will document the activities that connect the UNC Gillings School of Global Public Health with public health and health care delivery institutions in France The work is supported by a Gillings Visiting Professorship awarded to Thomas C. Ricketts, Ph.D., M.P.H.