Today we heard the disappointing news that key Senate moderates,like Rob Portman of Ohio, are gradually getting on board with the travesty that is the American Healthcare Act. One of the most concerning concessions they appear prepared to make is the end of the Medicaid expansion introduced by Obamacare. They are buying into the Republican narrative (shared, though for different reasons, by some in the Bernie Sanders wing of the Democratic Party) that Obamacare’s problems somehow prove that a mixture of public and private coverage cannot work together. The Republican solution is to make healthcare entirely private; many on the left want to make it entirely public. I think instead, we should take a look at the great work France has done to cover its people through a mix of public and private healthcare sources.
The French government has two roles in the healthcare system: it has a health ministry that sets a national healthcare strategy and imposes cost control regulations, and it provides a National Health Insurance program, or SHI. The SHI is financed by a variety of taxes, including employer and employee payroll taxes, income tax, tobacco and alcohol taxes, and taxes on insurance and pharmaceutical companies. SHI covers French residents who are employed, recently unemployed, students, or retired persons. The state pays for insurance for long term unemployed residents and refugees. In addition to SHI, French residents can add voluntary health insurance, which, like in Germany, mainly covers additional benefits and the costs not covered by SHI. All employed French persons are entitled to some level of VHI. While the French do pay coinsurance for their medical care, these rates are generally extremely low. On the whole, the French system is incredibly effective, and what we can learn from it is that it has slowly evolved over time to cover more and more French people because French leaders were committed to covering everyone and limiting cost, while working with healthcare professionals to help them ensure they are adequately compensated. I asked Pomme Tarte, a translator who has lived in St. Germain en Laye, a suburb of Paris, for almost 40 years, to tell us about a conversation she had with a couple of French doctors about what it’s like to work in the French system, and how they feel about it. Here is her report, (edited for flow):
Are you a specialist or a general practitioner?
Guillaume is a retired family doctor (GP).
Marielle is a retired specialist (specialties: endocrinology, nutrition, diabetes mellitus)
Do you feel that you are able to provide care to your patients in a timely fashion?
Patients can get an appointment within the week. A patient can call if urgent and the secretary can determine if it really is urgent. If so, the doctor takes the call and decides what to do. It used to be that doctors made house calls. While they still do, they do so much less. There are fewer doctors setting up their own town practices, apparently. The administrative side and overhead are a disincentive. There exist health centers where staff is on the payroll. The patient can’t expect to see their particular doctor, so it’s not the same relationship. (Note from Pomme Tarte: This may be a trend, but it is not very visible in Saint Germain en Laye).
To get an appointment with Marielle, or most specialists, one needs to wait three months or so. She spends half an hour with the patient. If an urgent call comes in, she takes the call or gets back to them and evaluates the situation.
She used to have a secretary with all the problems of an employer. Then she got a call service to handle her bookings and phone needs, which helped with costs.
What about Patients who fall ill on a night or weekend?
They go to the ER or call SOS Médecins to see a doctor. Ours is: http://www.sosmedecins-yvelines.fr/ There is an office of “SOS Medecins” (A French emergency service that serves as a sort of urgent care center/urgent house call provider) in a nearby town where you can see a doctor during the daytime hours on a weekend. Otherwise, SOS Médecins will put you on their list and drive to you. It takes awhile, because they have to drive all over the place, but you can stay home and wait. You get charged more, but it is an option to avoid going to the ER.
Too many people go to the ER when it is not a real emergency (Note from Pie Face: apparently this is not just an American phenomenon!).
How do people get to see specialists in France?
Guillaume says his patients choose him to be their “médecin traitant” (primary physician). He is then the gatekeeper to the specialists. A patient has to go through the médecin traitant in order to see a specialist. Marielle noted that this saves the health system money. It used to be that a patient would decide on their own to go see a specialist, but see the wrong one, etc., or see several wrong ones. The SHI pays its share of 23 euros for the GP instead of 150€ for a specialist.
There are kinds of specialists that a patient can see without going through the médecin traitant: GYN, opthamologist, psychiatrist, stomatologist.
If you have an emergency, you dial 15 and they decide what your course of action should be and send you emergency care or ambulance, if necessary.
The price of seeing your médecin traitant is 23 euros. That is the price reimbursed by the SHI. The reimbursement rate is 70%. You pay your doctor, the doctor files the paperwork with the SHI, the SHI covers 70% and your VHI covers the 30% not reimbursed by the SHI.
Are advanced new drugs available to patients in your system?
Drugs are approved by the French authorities (like the US FDA). Once a drug is approved, it is theoretically available. A doctor might prefer to prescribe an existing medication that works perfectly well rather than a expensive new one.
For some types of drugs, the patient has to get them prescribed at a hospital. There is a framework regulating the prescription of certain types of drugs (anxyolitics, etc.) For instance, the drug for Hep B chronic is expensive and specialized, must be prescribed by a specialist. At a hospital, there is no limit on what a doctor can prescribe for HIV or cancer or whatever.
The French system sends out a rep to remind doctors about “best practices” from time to time. If a doctor in private practice has a question about, say, antibiotics, s/he can call the Service des Maladies Infectieuses at the hospital for information.
Does your system lead to any kind of rationing? What kind of compromises do you think the system has made in terms of patient care to make it more affordable?
It organizes, but does not ration. The obligation to go through the médecin traitant is an example. No compromises are imposed. Very old people are given care (operations etc.). Their age is taken into account for treating them. The doctor gives care to benefit the patient. I’m sure they consider cost/benefit, but cost/benefit is not imposed on them.
Do you feel able to provide the same care to patients on the social system as you do to those with private insurance?
Everybody can get health care through the system, even hobos on the street with the State coverage for the indigent and refugees (CSU). The SHI pays 100% for a “CSU” doctor’s appointment.
Doctors are organized in Sectors: (Sector 1: they charge the SHI rate. There is an advantage somehow on the retirement end for these doctors. Sector 2 doctors charge more. The VHI has more to pay.
A doctor is not legally obliged to take on a patient with CSU. Marielle and Guillaume said the doctor has a moral obligation, but not a legal one. Both Marielle and Guillaume had CSU patients. But, at the end of the day, if the doctor has had too many CSU patients, s/he is not going to be happy.
- When you look at the rest of the world, what is the best part of being a doctor in France? What is the worst?
The best: Marielle and Guillaume said the average price in Europe for a consultation is 50 euros v. 23 euros in France. They had the impression that in the UK doctors earned more and worked less (Note from Pie Face: English doctors DEFINITELY do not make more money. They are in real trouble at the moment due to funding cuts.). Also, a doctor can set up business where they want (there are rules about distance from another specialist, but basically it’s up to the doctor where s/he wants to practice). Pleasant places are full of doctors!
The most modern MRI in this area is ten minutes from St Germain, in Poissy. The hospital in St Germain has been partnered with Poissy for resource sharing purposes. We no longer have an ER at night. The maternity ward used to deliver 2000 babies a year, now it’s all Poissy’s excellent maternity ward or else you go to the local clinic (which has set up shop right next to the hospital). Apparently the opthalmology and endocrinology and infectious diseases people at St Germain are great, it depends on the department.
The worst: The hospital system is cumbersome, administrative, not flexible. In France, things could be improved, but they basically think it is a system to be proud of.