The French way of cancer treatment | Anya Schiffrin

An account of cancer care in France.

When my dad began to get worse, the home visits started. Nurses came three times a day to give him insulin and check his blood. The doctor made house calls several times a week until my father died on December 1.

The final days were harrowing. The grief was overwhelming. Not speaking French did make everything more difficult. But one good thing was that French healthcare was not just first rate — it was humane. We didn’t have to worry about navigating a complicated maze of insurance and co-payments and doing battle with billing departments.

Every time I sit on hold now with the billing department of my New York doctors and insurance company, I think back to all the things French healthcare got right. The simplicity of that system meant that all our energy could be spent on one thing: caring for my father.

That time was priceless.

The French way of cancer treatment | Anya Schiffrin

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France: 'Best' Health Care?

I am taking an International Comparative Health Care Course this semester, so will be adding to my US/World Healthcare Comparison tag I'm sure. Here's a piece from CBS Sunday Morning on France. The second half, showing the EMS triage system is pretty impressive.

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The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States -- Rodwin 93 (1): 31 -- American Journal of Public Health

The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States -- Rodwin 93 (1): 31 -- American Journal of Public Health:

Keepin' it real. Every system comes with trade-offs...

THE FRENCH HEALTH CARE system has achieved sudden notoriety since it was ranked No. 1 by the World Health Organization in 2000.1 Although the methodology used by this assessment has been criticized in the Journal and elsewhere,2–5 indicators of overall satisfaction and health status support the view that France’s health care system, while not the best according to these criteria, is impressive and deserves attention by anyone interested in rekindling health care reform in the United States (Table 1). French politicians have defended their health system as an ideal synthesis of solidarity and liberalism (a term understood in much of Europe to mean market-based economic systems), lying between Britain’s 'nationalized' health service, where there is too much rationing, and the United States’ 'competitive' system, where too many people have no health insurance. This view, however, is tempered by more sober analysts who argue that excessive centralization of decisionmaking and chronic deficits incurred by French national health insurance (NHI) require significant reform.

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Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker

Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker:

"Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” In the battles between Betamax and VHS video recorders, Mac and P.C. computers, the QWERTY typewriter keyboard and alternative designs, they found that small, early events played a far more critical role in the market outcome than did the question of which design was better. Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area—even if prices, taxes, and competition are stiffer. “The long shadow cast by history over location is apparent at all scales, from the smallest to the largest—from the cluster of costume jewelry firms in Providence to the concentration of 60 million people in the Northeast Corridor,” Krugman wrote in 1991.
With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one."

It's actually hard to get a representative paragraph out of this article. It is definitely worthwhile reading, as is everything Gawande writes, and begins with an overview of how universal healthcare took hold in England, France and Switzerland, and then makes the case for "path dependence", which starts the section I've quoted above.

Because I haven't written it in a while, Ill repeat a story. At a debate among single payer advocates and antagonists at Duquesne University last year, I asked the representative of the very right wing Fraser institute of Canada, which of the world's nations systems he could live with us modeling ourselves after. Switzerland was the answer, and he conceded that the hybrid of using competing insurers and providers while requiring universal coverage with subsidies may be the second best solution for America. After laissez-faire capitalism, of course.

But it does make the point that the combination of path dependence and bits of common ground could lead us to real change.

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France - OECD Summary

Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell

France
• 79% of all care is publicly financed
• Employer and employee payroll taxes account for 43% of the funding. The employer pays 12.5% of payroll and the employee pays 0.75% of payroll.
• Part of the national income tax goes to funding health care and accounts for 33% of the funding.
• Tobacco and alcohol taxes supply another 8% and state subsidies and other social security taxes provide another 10%
• Coverage includes everything except dental and eye.
• Cost-sharing occurs through coinsurance and co-pays and extra/balance billing
• Out-of-pocket expenditures account for 7.4% of the total health expenditure
• Private health insurance accounts for 12.8% of the total health expenditure
• The public funding goes to public health insurance funds with membership based upon occupation
• Benefits/prices/cost-sharing levels are determined, since 2004, by the national Union of health insurance funds (UNCAM)
• Low income persons also get free complementary-supplementary coverage including dental and eye and they qualify for no balance billing
• Private insurance is like our supplemental policies. It reimburses for the cost-sharing elements of the national plan. This is usually provided by employment-based insurers called "mutuelles" . 90% of the population gets this. So far there is only a minimum competition in this market.
• Physicians, non-hospital-based, are self-employed and fee-for-service. Hospital-based physicians are salaried.
• Two thirds of hospital beds are either government-owned or nonprofit.
• One third hospital beds are private located in for-profit clinics and, I believe, in hospitals as well.
• Hospital reimbursement is moving to a DRG style system. Hospitals do get subsidies for research and teaching and emergency care.
• There are some cost controls in place. Controlling formularies a big issue at the present time according to my interview with Dr. C'alloch in Paris.

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Health Care System Profiles

Health Care System Profiles:

"The work of the Commonwealth Fund's international program highlights the valuable lessons the U.S. can learn from the health care systems in other industrialized countries. These country profiles provide overviews of the health care systems of several countries, including Denmark, France, Germany, the Netherlands, Sweden, and the U.K. Each profile includes descriptions of how each country organizes, finances, and delivers health services and highlights quality, efficiency, and cost-controlling policy initiatives and reforms"

Follow the link to this page at the Commonwealth Fund website to download individual country profiles or the whole thing.

Here is a remarkable slide presentation from the Commonwealth Fund aggregating in PowerPoint form, a large quantity of data on systems around the world.

Continuing my education in international comparative health policy...

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Interview with Dr. Calloc'h, of France's Chambre du Medicine

Interview with Dr. Louis-Jean Calloc'h, Auditeur au Conseil National de l'Ordre des Médecins and Secrétaire-Génèral de l'Association Médicale Française and Director of International Affairs for the Chamber of Medicine of France

In France, "a 'G-P Specialist' is a G-P who practices and has a quite exclusive and verified good and permanent practice in general medicine. Not an other not referenced opposed verified practices: homeopathie, acupuncture, psycological-consultations. The others are simply G-P."

Economic pressure is forcing physicians to become specialists. In the past in France you were able to go to any physician but there became restrictions on access to cost restrictions. The GP is still the gatekeeper. A patient is not allowed to go directly to a cardiologist or other specialist without using the gatekeeper function. This is a recent change.

Training is changing. In the past, it required approximately 8 or nine years of training to become a GP. It took two or three years after that to become a specialist. But now GPs are becoming specialists: I think he's saying here that a GP can get additional training at the University to get further qualifications. It's not clear to me the difference between GPs with a traditional training versus true specialists. It sounds like it might be that one becomes a GP specialist in cardiology and therefore sees more patience with party logic problems but they are still not true cardiologist specialists. And they still perform a gatekeeper role before the patients get to the true specialist. It sounds like the GP and the GP specialist both are in charge of handling the ministerial and medical record-keeping work in the system. Keeping the dossier, as Dr. Calloc'h says.

Dr. Calloc'h notes that patients can be put on the list, for example, of diabetics who require more advanced care. These patients can then go see an endocrinologist directly several times a year. There are limits to how many erect visits the patient can get. The idea is apparently to make the primary interface with a primary care physician can not a specialist. He specifically said that specialists such as cardiologist and endocrinologists do not perform primary care functions.

The GP is the person who interfaces with the single-payer entity. The GP also develops a care plan. This plan may specify a number of visits to a specialist. If the patient exceeds the number of visits they then have to pay out of pocket. There is a list of from 20 to 22 diseases that are specifically supposed to be managed with a plan by the GP. He gave several examples including hypertension and diabetes obesity and some others that I didn't catch. It sounds like these patients that also signed a contract with some details of their management plan including specialist visits. Now here Dr. Calloc'h indicates that a specialists may actually act as a GP for some of these patients. He called it the "Reseau," which is a kind of managed care contract. The réseau is a contract that the GP or specialist also signed with the single-payer and agrees to manage the patient. The Medical Society, Chambre Du Medicine, seems to be advocating for this approach, but the trade unions do not. The chamber also would rather see multiple players for more competition. It's not clear to me what the competition would center around.

Dr. Calloc'h: "The "Assurance Maladie or CNAM" is so powerfull in France that, today, there is quite no economique competition with other public or prived medical care insurance. Only one entity to negociate with."

Trade unions. It took a little while for me to figure this out, but the physicians have trade unions. So, when he was talking about trade unions, he was asked a talking about the physician trade unions who sound to me to be the advocates for the physicians on economic matters. As opposed to the chamber of medicine, whom he represented, who were more the professional watchdogs and ethical watchdogs. For the trade unions, the single-payer is a big problem because there is only one entity to negotiate with. This seems to be why they would like to see multiple payers.

Generally people pay the physician. Poor people get a card to excuse them from payment. If the patient is without means and has complicated multiple illnesses, apparently one has to appeal to the single-payer for credit on the card for more frequent visits etc. For the people who do pay, currently the fee is €22 but this will be rising this coming year. Interestingly, it sounds like the complexity or time of the visit is immaterial. He said a 4 or 5 minute visit gets the same fee is a more complicated visit. However the more you do, such as EKGs or blood work, the fees accumulate. He said something in here about the patient's then getting reimbursed by the single-payer, but only about €17 for a visit. So this functionally works out to a five euro co-pay. Some patients buy supplementary insurance so that even that small co-pay is taken care of.

He makes the point that GPs are expected to be able to do everything except the most dangerous of procedures. He feels that this is asking too much and that some physicians make the mistake of being too proud and believing that they can do anything. And this is something that the chamber of medicine handles, and it's role as what we would call a state Board of medicine. France has civil sanctions, administrative sanctions and penal [criminal?] sanctions. The Chamber of Medicine is responsible for the professional sanctioning. It is akin to a state Board of Medicine however it is run from within the profession and not from the state or national government. Complaints can come from patient to patient organizations or from other doctors. Apparently the complainants and lawyer decide whether something can be handled through sanctions or through civil law, which sounds like medical liability action. He says that he feels this is having a chilling effect particularly on young physicians who are now more worried about liability. He also indicates that this is slowing the activity of the Chamber of Medicine because of concerns with the civil liability aspect of the case. So where they might act quickly in the past they now are more circumspect and take more time to make a decision. Dr. Calloc'h feels the France is about 15 years behind where the US is regarding medical liability. He indicates that France now has lawyers who specialize in finding medical liability cases much as we have here in the US.

[Dr. Calloc'h has updated me that he thinks they have nearly caught up due to their new lawyers.]

Half of physicians in France are GPs. There are limited number of specialists. This is due to specific decisions made by the single-payer, apparently. The decision was made that too many specialist made care too costly and that this had to be stopped. Apparently the thinking was that too many doctors led to many prescriptions and too many prescriptions increased the cost of care. "So stupidly, they decided 15 years ago to make the big selection(?)"-- not sure if he meant here about cutting training or something else.

And what of the most pressing concerns of physicians under the French system? The pressure of lawyers and prescription restriction. The first is obvious, the second simply refers to pressure to prescribe generics and formulary restrictions on expensive medications. And the patients are specifically asking for the newer, better medication. The single-payer keeps statistics on each physician and they know when you prescribe to many antibiotics for example. They will then send someone out to talk to you. If this keeps happening you can get an administrative sanction. This can then turn into an economic sanction where they single-payer will refuse to reimburse patients for their visits to you. Obviously this is fairly severe. It sounds like much of this takes place in the context of your position neighborhood and what others in your area are prescribing or not.

The Chamber of Medicine is apparently not allowed to advocate politically. Political advocacy therefore takes place either through the universities or the trade unions (and maybe the specialty societies?). There are trade unions for GPs and for specialists also. It sounds like you typically belong to your specialty's trade union and its academic society.

I will keep updating this as I receive clarifications from Dr. Calloc'h.

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France's model healthcare system - The Boston Globe

France's model healthcare system - The Boston Globe:

"National health insurance in France stands upon two grand historical bargains -- the first with doctors and a second with insurers. Doctors only agreed to participate in compulsory health insurance if the law protected a patient's choice of practitioner and guaranteed physicians' control over medical decision-making. Given their current frustrations, America's doctors might finally be convinced to throw their support behind universal health insurance if it protected their professional judgment and created a sane system of billing and reimbursement. French legislators also overcame insurance industry resistance by permitting the nation's already existing insurers to administer its new healthcare funds. Private health insurers are also central to the system as supplemental insurers who cover patient expenses that are not paid for by Sécurité Sociale. Indeed, nearly 90 percent of the French population possesses such coverage, making France home to a booming private health insurance market."

I think that, except for the hard core ideologues, physicians would by and large accept this bargain.

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What Jacques Chirac could teach us about health care

What Jacques Chirac could teach us about health care: "What Jacques Chirac could teach us about health care.
Comparative Advantage
by Jonathan Cohn
Only at TNR Online Post date 04.10.07 "

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