Today in France: Making good things better(?)

In their year 2000 World Health Report (full Report (.pdf), or consult by chapters from here or read the Press release), the World Health Organization (WHO) found that France had the best overall healthcare system among its 191 Member States. In comparison, the United States, despite pouring more of its gross domestic product into healthcare than any of the other nations, managed only a 37th place in their results. Michael Moore hammered this home in his film “Sicko“, a scathing criticism on the failings of the American health insurance system. Mr. Moore of course pulls all the strings he needs to to make his point, including painting the French medical landscape as a sort of healthcare utopia. There is, of course, room for improvement even in the French system. With that said however, my personal worst nightmare would be to find myself again in the American system.

But yes, France’s system can be improved and several news items this past week illustrate opportunities.

Fighting nosocomial infections

A nosocomial infection is an infection that originates in the hospitalized setting. They are the bane of hospitals world over. By its very nature, a hospital promotes the proximity of illness in combination with frequent invasive techniques; because of this the total elimination of nosocomial infections is virtually impossible. However any decent healthcare system must do everything it can to reduce their frequency.

The French Health Ministry reported (.pdf in French) this past week significant improvement over the past few years in the efforts made by French hospitals to minimize nosocomial infections. Several indexes were used to determine progression, most notably the Health Ministry’s Icalin index (site in French) (Indice Composite des Activités de Lutte contre les Infections Nosocomiales). This index gives a weighted grade from “A” to “F” to hospitals and other health institutions, based on their actions against nosocomial infections. In 2006, over 80% of responding French hospitals received a rating of “A” or “B” (Hospitals that do not respond receive an “F”). In comparison, only 33.3% of hospitals had these ratings in 2004. These efforts resulted in a 12% reduction in nosocomial infections between 2001 and 2006. The percentage of patients infected in the hospitalized setting in 2006 was 4.97%, making France a top-runner in Europe, where nosocomial infection rates very between 4.9 and 8.5%.

Paradoxically, only 11.2% of hospitals received good marks for hand hygiene. The Health Ministry will be engaging in actions to improve this problem on 23 May, with the first “National hand hygiene day”.

On this same day, France will be signing what the French press is calling the “Charte pour des soins propres” of the World Health Organization. I think what they are speaking of is the “Défi mondial pour la sécurité des patients” or in English the Global Patient Safety Challenge, but I’m not sure about that. If anybody out there can clear up this point don’t hesitate to leave a comment.

Controlling healthcare fee abuse

The French healthcare system is socialized, but that does not mean that doctors and hospitals work for free. However, as the majority of healthcare fees are paid by the government, and what isn’t is picked up by employer-provided complementary insurance, a certain culture of abuse has unfortunately wormed its way into the French psyche, putting in danger the economic health of the system and occasionally patient care.

Reforms meant to reel in expenses and remind healthcare consumers and providers of their responsibilities have already been, or are being, put into action (site in French).

The laws controlling the French healthcare system allow for the exceeding of statutory fees for specialized care, that’s to say virtually everything that’s not a simple visit to the family physician. Almost all specialists (dermatologists, cardiologists, ophthalmologists, etc.) take advantage of these honoraires libres, knowing that for most patients this won’t be a problem thanks to the employer-provided complementary insurance policy. In principal, even these extra charges are subject to French public health law, and the specialist have deontological limits on what the can charge per act, but in reality, certain abuses have been noted. More importantly, this exceeding of statutory fees hampers access to healthcare for those who do not have complementary insurance.

In order to resolve the problem of abusive physician’s fees, a new proposition would oblige doctors to provide written estimates to their patients, clearly indicating the interventions and the fees that will be charged. Estimates would only be required for medical interventions over a threshold price, probably in the neighborhood of 80 to 100 euros.

Although agreeing that an estimate would be a step in the right direction for open and clear doctor-patient communication, the CSMF, the major syndicate of private-practice physicians, did express its worries that such an act may create as well a climate of distrust.

My initial impression is that such a law will indeed have a positive effect on healthcare in France because patients could in theory get several estimates and compare physicians. A physician hoping to slide in excessively high fees or unneeded medical actions would be obliged to think twice before doing it. The net effect, one would hope, would be a better experience for the patient as well as a reduction in costs for the French healthcare system.

Currently, the project is being presented as strictly a doctor-patient document: transparency, open competition and all that. However, the eventuality of third-party interference troubles me. Indeed, when statutory doctors’ fees are exceeded, it is the companies providing complementary insurance that historically foot the bill. Are thus those who have complementary insurance going to experience a dérive à l’américaine, where suddenly it’s the insurance company that says yes or no for an intervention?

Affaire à suivre…

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