Editor’s note: This is the fifth 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.

As we ended the last session of the Council’s international mission in Paris on Friday, delegates reflected on the learning opportunities offered to them over the past five days. We began the trip anxious to understand what France was doing to achieve its strong outcomes and low health care GDP. Many insights were gained, but, as in so much with health care, there is no simple answer.

We assumed quality measures would help us understand the country’s health standings, but were surprised to discover that little data is available in this area. There isn’t standardization across the system and we found no organized effort to collect data. Most Council delegates agreed that since patients who want reimbursement for doctor visits did use their general practitioner to monitor their care, there is an understanding of the importance of primary care in France, something the U.S. has been emphasizing more only in recent years.

We discussed France’s firm commitment to freedom of choice. But while choice is there in theory, we had questions about whether there were true choices throughout the country. In more rural, economically depressed areas, there is an access problem and lack of providers. Even in the urban, wealthier areas, private hospitals appeared limited in the services they were allowed to offer.    

Among the experts we spoke with, opinions were varied as to the degree of satisfaction with the system. There is not widespread commitment to wellness or prevention, nor an understanding of their relationship to controlling health care costs. And, although the country doesn’t appear to have the large obesity problem we do in the U.S., it was noted that many of the health care professionals we came into contact with were smokers – including one who talked about the importance of smoking cessation.

There is no doubt that the French have a better system for the poor to access and receive health care. And perhaps because of good prenatal care for all expectant mothers, France does have a lower infant mortality rate than the U.S.

There is definitely an entitlement mentality here. And, without doubt, in France, it is believed that health care is an inalienable right. 

The differences between the French and American systems are complex and cultural. We are at different stages and, as one speaker noted, it appears that the French are shifting closer to the U.S. system while health care reform in the U.S. is shifting us more towards the current French system.

Editor’s note: This is the fourth 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.

Nashville Health Care Council members on the International Mission in Paris started their day with a discussion about their impressions of the French health care system based on the first three days of meetings, presentations and hospital visits. Among the comments:

• We heard a lot about the need to control costs, but no clear plan.
• There have been many good things we could learn from the French, but their operational processes are not similarto those in the U.S.
• French patients receive all their health care information from the government and providers, not from advertising or the media as in the U.S., so there is no level of consumerism.
• What will change the system here? Will those who can pay for care drive it?
• The French have a centralized system but still struggle with many of the same issues we do in the United States.
• There is a hierarchical structure that makes it difficult to report problems with physicians.
• There is no motivation to commit fraud when there is no profit in it.

The rest of the day’s activities included a panel with French private health care CEOs, a briefing on the public-private partnership between France and Franklin-based Healthways and discussions about hospital performance, the utilization of e-health tools and health care financing trends in the European Union.

Much of what the CEO panel told us confirmed what we heard earlier in the week. The current system was created in a time when it was believed that health care is priceless, but in today’s world it does have a cost and the government that controls it has less and less money.

There is growth in demand, but it is difficult for the private hospitals to get approval to provide services to meet those demands as the government tends to favor public hospitals. Sensitivities for the private providers are physician fees, drug costs and reimbursement. On the positive side, outpatient services are profitable and growing and private providers are shifting toward them.

The session closed with a panelist saying, “We must rebalance a system that is at risk.”

To that end, the next session highlighted Sophia, a partnership between the public insurance system in France and Healthways. It is based on the recognition that the insurance system needs restructuring for more cost efficiency and needs to move from being a payer to being an active risk manager that encourages citizens to participate in their own well-being.

The pilot program, launched in 2008, was focused on diabetes and has seen improvement in diet and exercise and treatment compliance among participants. The team will tackle asthma and cardiovascular disease beginning this fall.

The discussion about performance reminded us again of the cultural and philosophical differences between France and the United States. Performance measurement is a new concept here and one that is not popular. The country has always spent a lot of money on health care but never before asked for accountability from providers or patients.

The government has formed an agency to assist in improving performance. It is working hand-in-hand with providers and regional health authorities on a hospital-by-hospital basis so that each can learn from the other’s best practices. The effort is just a few years old, and while improvements have been made, leaders feel there is still room to improve.

The e-health arena is another area that needs improvement. The director of ASIP, France’s public agency of shared information system for health, cited the need for the right balance between regionalization and centralization as well as defining the role of public versus private involvement.

As in the U.S., privacy concerns also present e-health challenges. We learned earlier in the week that the supplemental insurance companies are not allowed to keep data about members, either individually or aggregated. Using information technology to streamline the system is a long-term goal.

Editor’s note: This is the third 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.

What better way to understand the health system in France than to visit a hospital? Today, our group of Nashville Health Care Council members divided up to tour a private not-for-profit hospital, a private for-profit hospital and a public hospital in Paris. On our tours, we found trends and challenges similar to those at American hospitals, including more hospital-employed physicians, increased employee recruitment needs and static reimbursement levels.

American Hospital of Paris

The 144-bed American Hospital of Paris, a private, not-for-profit hospital, finds expansion of services difficult for two reasons: 1) The high cost of land in Paris makes physical expansion difficult and 2) The government limits the services private hospitals can offer. To help overcome this, AHP markets to foreign patients, who now account for 40 percent of its revenue.

The hospital, pictured here in a Wikipedia photo, has 782 employees and 376 doctors. As a not-for-profit, it must charge its patients, who then are reimbursed by social security and, if they have it, their private insurance. AHP also solicits private donations to offset operational costs.

The hospital’s history is worth a note. It was founded in 1904 by an American doctor and a French doctor in part to treat the many Americans living here at the time. It was used to treat American soldiers in World War I and during the German occupation in World War II, an American doctor used it to shelter British, Canadian and U.S. airmen who had been shot down over France. Its mission is to provide the best of American and French care.

Clinique de l’Alma

The Clinique de l’Alma, a 60-bed private, for-profit hospital also relies on foreign patients for revenue. A nephrologist and his family own 75 percent and an investment fund owns 25 percent. The hospital’s primary services are dialysis, urology, orthopedics, gynecology and gastroenterology. It has 150 employees and 60 doctors.

Hospital leaders at de l’Alma identified a mix of operational and health practices among their challenges. As in the U.S., more hospitals in France are directly employing physicians. Many physicians here prefer the steady income of hospital employment. But the government only allows public hospitals to do so, putting the private hospitals at a disadvantage when it comes to recruiting medical staff. Officials also cited general human resources issues resulting from difficulty in finding qualified employees and strict hiring and firing laws.

France has seen an increase of two to three percent in renal disease due to aging and an increase in diabetes related to obesity. Interestingly, a drop in the availability of kidneys for transplants because of fewer traffic accidents also has driven the rise in demand for dialysis.

Hospital Saint Louis

Hospital Saint Louis, the public hospital our group visited, is part of Paris’ 37-hospital system. Saint Louis has 563 beds and 3,200 employees, which includes 700 doctors. As part of the tour, our group visited its dermatology museum, the site of the first school of dermatology built in 1800. Dermatology is still offered there along with a variety of services including hematology, oncology, plastic surgery, transplants and burn treatment.

The hospital collaborates with the others in the Paris system. As noted earlier, it also has the option of directly employing its own physicians but it shares the same challenges recruiting nurses and other employees. And as with the private hospitals, Saint Louis and the other 36 hospitals in the city’s system operate at a deficit.

It does have one marketing advantage. It has developed a state-of-the-art laboratory that cuts the time to process tests by as much as 50 percent. As a result, it is now working to win lab work from private and public hospitals throughout the country.

Again, we end the day reflecting on the similarities between the challenges and opportunities France faces with those we have at home.

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.

Editor’s note: This is the first in a series of posts this week from the Nashville Health Care Council’s International Health Care Mission to Paris. Look for more in the coming days.

On our first night in Paris, mission leader Senator Bill Frist summed up what this 10th International Health Care Mission is all about. He explained that, while we know that the French health care system has outcomes that surpass that of the United States achieved at a lower percentage of its GDP, few of us know much about how the system works. This week’s program will provide insight into the system, its challenges and its opportunities.

Sen. Frist also emphasized that the global friendships and networking opportunities offered through this delegation are significant and part of the Nashville Health Care Council’s organizational mission. He added that the group will not only experience the culture of Paris, but also see how Nashville’s presence is reflected in this global city as the Musee d’Orsay prepares to open a special exhibit of Nashville couple Spencer and Marlene Hays’ Impressionist collection.

To understand the French health care system, we first must understand the business climate and cultural mindset in France. In our first session, a team from the U.S. Embassy gave us an overview that highlighted the following:

• France is a major U.S. trade partner. We have a strong import and export relationship.

• While France is strong in developing technology and research and development, it lags behind in innovation and often looks to the U.S. for the investment and partnership needed to take those elements and create products and services from them.

• The French business community frowns on failure. In fact, French investors are not likely to give entrepreneurs a second chance. At the Entrepreneur Center in Paris, they have a zero failure rate based on that belief.

• The French government also plays an interventionist role in business as an investor in many of the country’s large businesses.

So what about its health care system? Health care experts from Deloitte Consulting France gave the group an overview. The French health care system is a combination of public entities and private organizations that are both for-profit and not for profit. There is a government obligation to organize the system but a strong belief in the freedom of choice. Nearly everyone in France has health insurance.

The health insurance system is based on three principles: equality of access to treatment, social solidarity and quality of treatment. Insurance is provided in three “schemes”: salaried employees (and family), unsalaried farm workers and independent workers.

The government provides oversight for the system and pays providers directly for services rendered within the system. All are encouraged to find a general practitioner to oversee their care. GP services require a co-pay of 23 euros per visit and, if referred to a specialist, a co-pay of 25 euros. Insurance covers reimbursement for most inpatient and outpatient treatments.

Sounds great, right?

The system is operating at a deficit. It faces many of the challenges we have here in the U.S. And public opinion is very divided on changing it.

In the next few days, we will learn more about the French system, its strengths and its weaknesses. Stay tuned for more insight and views from French government and private businesses involved in delivering care.

Members of Leadership Health Care, an initiative of the Nashville Health Care Council, are preparing to attend the 11th annual Delegation to D.C., to be held March 13-14 in Washington, D.C. The two-day trip attracts approximately 85 LHC delegates each year and allows attendees to meet with industry heavyweights who provide insight regarding issues impacting health care. Post sister publication Nashville Medical News has a preview story here and will provide updates (to which we will link) during the next week.

Music Row-based branding and interactive firm Powell Creative has named Sheri Young as account services director and Tiernee Harris as social media coordinator.

Young (on right in photo) was formerly director of marketing for Woodridge Development, Inc. Prior to that, she served as director of sales and marketing for Healthsource Rx, a subsidiary of Cigna/Healthsource.

Harris was previously a communications intern for the Nashville Health Care Council, a publicity intern for Warner Music Nashville and an artist management intern for O-Seven Artist Management.