NHCC in Paris: Problems general and specific that sound very familiar

Editor’s note: This is the second in a series of posts this week from the Nashville Health Care Council’s International Health Care Mission to Paris. To view others, click here.

Jean-David Levitte, former French ambassador to the United States and senior diplomatic advisor to former President Nicolas Sarkozy, started his keynote dinner remarks Monday night by thanking us as Americans for two blessings we have given to France: D-Day, where American soldiers died for France, and the Marshall Plan, which he called the origin of the European Union. 

Ambassador Levitte went on to talk about the formation of the EU, the introduction of the Euro in 1998 and its 10-year success story. He noted that, although success began faltering in 2008, the EU is working to improve its economic situation. And, he spoke of France’s ongoing efforts to reform its pension, health care and education systems while reducing state spending. 

Sound familiar? 

Today, we spent the morning at the National Assembly hearing from members of Parliament — two of whom were also cardiologists — and the director general of a regional health authority in the Languedoc Region. In the afternoon, we heard from representatives in the pharmaceutical and insurance industries. All of these experts seem to agree with the following ideas about the French health care system:

• The concept of universal coverage, with all parties taking part in the management of the system with transparency and the freedom to choose, is good in principle.
• The national government makes the overall policies, controls funding of the social security system (which includes health care) and each of the 27 regions adapt the regional policies to deliver and manage care and coordinate costs. This includes public health, prevention, environment and the provider systems.
• Parliament ensures a balance between income and expenditures for hospitals, clinics, providers and pharmacies.
• Good quality care is available regardless of income.

But all of our guest speakers also agreed that, as the system has evolved since it was first introduced in the 1940s, it has encountered a number of challenges. One speaker called it a paradoxical situation, “a praised system from the outside” for its outcomes and GDP expenditures, but “criticized from the inside” and that while reform was being implemented in many counties, France is resisting it. 

So what are the challenges they cited?

• The system is experiencing a 10 billion Euro deficit and there is no mechanism in place to increase reimbursement to doctors, hospitals or pharmacies.
• Physician access is an issue in poorer areas. While there are enough physicians per capita, they are not evenly distributed. For example, in Nice on the coveted French Riviera, there are as many dermatologists as in all of Holland. Yet in northern parts of the country where the economy is suffering, there are none. Doctors don’t want to practice in poor areas.
• Physician payment is based on activity, not quality. The more patient visits doctors have, the more money they make regardless of outcome. Although several speakers did also stress the deep commitment doctors have to their patients.
• The focus is on delivery of care, not prevention. There are no incentives for prevention and most agreed this is an area where France is lacking.
• Pharmaceuticals are highly regulated. All pharmacies are independently owned by a single pharmacist. Formularies are limited and reimbursement rates are static. 

Still, the French system has many merits even if it slipping on rankings of outcomes and spending. Tomorrow, we will divide into groups to visit three hospitals — public, private not-for-profit and private for-profit — to see the system up close and hear from the providers themselves.