Patients’ Rights in France

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

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

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

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

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

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

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.