Wednesday, July 29, 2009

France Anecdote

Anecdote's aren't necessarily good health policy...in fact, I saw an ad on TV and a lady said if I wanted Canadian style single payer, I wanted her dead! [By the way, the largest single payer health insurer in North America is U.S. Medicare; there are more Medicare beneficiaries than Canadians, but I digress].

But, I thought this essay that a reader emailed me was interesting. Most interesting, I thought, is the use of old style claim filing in France whereby you pay for care and then submit a claim. One thing about doing that is that it actually makes you more aware of how much money is changing hands....but the paperwork sounds like a pain. One approximation of a French-ish system would be a single payer offering high deductible care with a private insurance market in place to fit 'on top'. Here is a summary of the report I think she is referring to. Here are the gory details. Here is another in a similar vein, that is actually more useful, I think.

Primary Health Care in Two Countries
By Iris Kapil

Primary health care is basic medicine and should not differ much from one locale to another but, in my experience, it does differ. Within a five-day period I was treated for an infected wound both in France and in the U.S. In both places the care was thorough and fully competent. Of that there is no doubt. It was the contrast between its organization and its cost that I couldn’t help but notice.

On April 28, at JFK airport in New York, on my way to Paris, I fell backwards on an escalator, landing on my back, hitting my head, making a bloody mess on the floor. In the Emergency Room the doctor found no need to stitch any of the cuts on the back of my head but he did give me a prescription for an antibiotic. He ordered CT scans and X-rays. No bones were broken. I had been conscious the entire time. After several hours in the ER and having returned to the airport, I discovered that I had lost the prescription – and my passport. There was nothing to do but return home by the next flight to Raleigh. Since I couldn’t see the cuts on my head and they didn’t hurt, I forgot about them. I applied for a new passport and in mid-May again took a flight to visit my son and his family in a suburb of Paris.

The cuts on my head healed, except for a bothersome one that developed a scab. It worried me enough that I asked my daughter-in-law to get an appointment for me with their family doctor. He told her that his schedule was full but he managed to fit me in on Thursday, two days before my flight home.

The doctor’s clinic is located, along with other medical and health related professionals, in a two story building on a square in a residential neighborhood. The waiting room is modestly furnished to seat no more than eight people and, from what I observed, it serves both offices on the first floor. One other person was sitting in the room with my son and me. We had barely arrived when the doctor opened the door and directed us to his office.

The doctor’s office is not much larger than the waiting room. He has a large desk, cabinets and other sorts of medical equipment. Intake was his sitting at his desk, me on a chair across from him, discussing my problem. He had me sit on his exam table. He looked at the cut, pronounced it badly infected, cleaned the wound and was applying a medication when his telephone rang. He went to his desk, made an appointment for the patient who was calling and recorded it in a book. He returned to me, put a 10 cm (4 in.) square gauze compress over the wound and taped it down. I had acquired an odd-looking skullcap. He said a nurse must change the dressing daily for three weeks and he wrote two prescriptions. As my son and I left the office, the doctor walked the few steps to the waiting room and signaled in the next patient.

The doctor has forms from the national health insurance, Sécurité Sociale (Sécu for short), that he fills in and, at the end of a visit, gives to the patient. On the form he marks the procedures performed and the amount paid. For my visit his charge was 30 euros (about $40). This is the rate set by the Sécu. The patient pays the doctor and mails the form to the local Sécu office for reimbursement. The patient also mails a form to his/her mutuelle (supplementary, employer-based health insurance that most Frenchmen carry) or the Sécu does this directly. It is possible under the system to carry private insurance and pay some specialists, who are independent of the Sécu, far more than the Sécu rate.

At the pharmacy I bought, as prescribed, sixty packets of 10 cm by 10 cm sterile, vaseline saturated gauze compresses; a role of 5 cm wide dressing tape and a bottle of a type of iodine. All this cost nearly 30 euros and is covered by the Sécu.

My son checked a list of licensed nurses registered with the Sécu. We phoned a nurse located nearby and made an appointment. The next morning she met us at her one-room office. I gave her the pharmacy material and the doctor’s prescription for her services. She removed the doctor’s bandaging, along with some of my hair, and carefully opened a compress packet and the bottle of iodine. She put iodine on the wound and applied a fresh skullcap of gauze and tape to my head. I told her that I had a flight to the States the next afternoon and needed to have the bandage changed anew for the weekend. She ordinarily does not see patients on Saturday but made an exception for me. The next morning she redid the dressing, pulling out somewhat less hair this time. She said the wound was healing nicely. Both she and the doctor told me that I should not shampoo my hair for three weeks. Her charges were 21 euros (about $28) per visit.

On Thursday I had phoned my daughter in Raleigh and asked her to call our doctor’s office for me, for an appointment with my nurse practitioner. She talked, of course, with a clerk. (When I phone in about health related matters I get to talk with a nurse.)

The appointment was on Monday. Begin with a clerk at the waiting room counter. She confirms your appointment, asks for your insurance information, handles all the forms and takes your payment. Behind the scene, other personnel deal with the multiple insurance companies. An assistant ushers you from the waiting room into a small room where she measures your weight, temperature, blood pressure, ask about any pain you have. Then she leads you to an examination room. A lab facility and equipment and paramedical personnel are on-site for blood and urine testing.

The nurse practitioner met me in the examination room and pulled up my medical record on a computer. She removed the bandage, with a few strands of hair, and examined the wound. She said it was healing well and prescribed an antibiotic cream to be applied three times a day. No bandage would be necessary. I could shampoo my hair. The medical encounter finished, I walked back to the counter and the clerk.

The bill submitted to the insurance company was over $200. At the pharmacy, the antibiotic cost $50. These in addition to what the patient pays for medical insurance and in co-payments.

A further comment on this comparison of medical visits: Besides different system organization and cost, there is also a matter of differing health cultures, of differing perceptions about health, medicine and medications that are rooted in the larger culture and seep into the way medicine is practiced. For example, in the United States, Medicare reimburses in a limited way for chiropractic service, for the core procedure only, and in France, where homeopathy is widely accepted, Sécu reimburses at a low rate for certain homeopathic remedies when prescribed by an M.D. In my personal cross-cultural experience, I was surprised by the doctor’s prescriptions: the iodine, the elaborately packaged bandaging materials and, especially, having to see a nurse every day for three weeks. I felt more comfortable with the American nurse practitioner prescribing an antibiotic; it fit my expectations. I wonder how the doctor and the nurse practitioner arrived at his and her course of treatment for the infection I presented with. Was the influence of different health cultures partly in play? Perhaps.

As is well recognized by now, the French health care system outperforms the American. The W.H.O. ranks the French system, despite certain cost issues, as the world’s best. Statistics show the French to be healthier than Americans. In public opinion surveys the French express a high level of satisfaction with their medical care. There is universal coverage. The cost per person of medical care in France is about half the American cost per person. Medical expenditure as a share of GDP in France is far lower than in the U.S. The improved health care system we will eventually adopt need not duplicate the French but we can at least observe, analyze and learn from their example.

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