Senator Diane Feinstein has an amnesty bill that she sneaked through committee up for a vote tomorrow. What will McCain do ? Michelle Malkin is on the case but it will be a close call.
We’ll see what happens.
UPDATE: We won.
Archive for May, 2008
Amnesty tomorrow
Tuesday, May 20th, 2008Health Reform- a few further thoughts
Monday, May 19th, 2008UPDATE:The article here offers an interesting comparison between the French and British health care systems. Almost a controlled trial since the writer had one hip done in the NHS and the other in France. That article link is no longer valid but this one is interesting. Sound familiar ?
In recommending Medicare as the vehicle for the basic coverage in a national health plan modeled on the French system, I did not intend to suggest that Medicare, as that vehicle, would be a government agency. I was recommending a non-profit corporation funded by payroll or other contributions from beneficiaries. Medicare, in theory, is funded by the Medicare tax contributions of workers prior to retirement. A system for active workers would be called the same name and the two programs, plus Medicaid, would be rolled into one system. It would be funded, however, not by general tax receipts but by the assessment for health care, analogous to the French funds, the largest of which, CNAMTS, is for salaried workers. There are many other funds for other workers such as agricultural or managerial workers.
As far as the name is concerned, Medicare was the name for the health care program for military dependents when I was in the Air Force. The name was adopted for the retirement health plan in 1965 and the military then called its program “CHAMPUS,” and now calls it “Tricare.” The name is secondary.
My point is that this should be a non-profit corporation or foundation, sort of like CalPERS, the California pension program for government employees. Beneficiaries, employers, unions and providers should all serve on the board of directors. The retirement program, which is mostly funded by tax receipts now, can be represented by bureaucrats. Working people should be represented by their own members, elected or appointed, depending on the format chosen by members. This may be a very important part of the French system.
We have learned a lot about managing health care in the past 25 years. When I was in graduate school ten years ago, there were students in the same program from all over the world. This is a universal problem. I have consulted for the NHS when they adopted the “Fund Holding” reforms of Margaret Thatcher. The Labour government, once it took over from the Conservatives after Mrs Thatcher was no longer Prime Minister, made many disparaging remarks about Fund Holding, a reform with some similarities to American HMOs. However, they have kept most of the reforms in place.
In considering reforms, most critics of the US system look to Canada for ideas. This is because they are close to us and share our language and many of our institutions. They are not, however, a good model. I believe many mistakes were made and too much coercion was used in dealing with providers, a feature of our current treatment of doctors in the US. Because of language, few know much about the French health care system but those of us who have been working in health care, especially in surgery, are aware of the very high quality of care and innovation. We should also become aware of the similarities and of the very high level of satisfaction, both by patients and doctors.
Health Reform- the transition
Saturday, May 17th, 2008I have been reviewing the details of the French health care system, as it was established in 1945, and how it has evolved in a history somewhat similar to our own. The Second World War marked the divergence between the two countries. Wartime labor shortages left us with an employer-based system that has become too expensive and rigid. France, in the social upheaval of defeat, had the chance for radical reform and took it. Britain took a similar opportunity and went another way with single payer, tax supported health care in the NHS. The pre-war differences in the three countries made some of this probable, if not inevitable.
What do we do now ? Why is it necessary to reform the US system ?
Our system is very expensive and does not have universal coverage. Those are the two features most listed by critics. People who are covered are largely satisfied with the care they receive but are often uneasy about the cost and the possibility of being left without coverage if they develop a serious chronic illness or lose a job. Our system has evolved away from community rating, in which everyone paid the same premium based only on age and sex. Now we have experience rating, in which a history of illness can make us uninsurable.
One of my patients 20 years ago had had a thyroid cancer, a form of cancer that is 100% curable when properly treated. A couple of years later, she needed a breast biopsy for what was almost certainly a benign lump. Her insurance excluded coverage because she had had thyroid cancer, totally unrelated to the present condition.
Recently, it has been reported that almost all medical groups in California are financially insolvent. For decades, the American system relied on cross-subsidies as insured patients paid for those without insurance by funding hospitals and doctors’ practices, which, in turn, cared for the poor and uninsured for free. The development of managed care and HMOs has eliminated the cross subsidy by squeezing out of the system the resources to provide uncompensated care. No one ever went without acute care in our system. Chronic illness has been another matter, but many of the patients who rely on emergency rooms and charity hospitals would probably not have availed themselves of chronic care anyway. Now, acute care is in jeopardy as public health systems, like that of Los Angeles County, are being bankrupted by the demand from illegal aliens.
How do we proceed ?
The United States is much larger than France with a much larger population, 300 million compared to 64.5 million. Our economy is much larger and healthier with an unemployment rate of 5% vs 10% or higher in France. Our people tend to work longer hours and produce more per worker. Some of the French problems with health care are, in fact, problems with their economic model, which is more protectionist and less productive with huge agricultural subsidies (even larger than ours) and excessive vacation time and early retirement. The French health care system would fit our economy better than a British or Canadian model and the relative cost would be tolerable. Ours is already based on payroll deductions rather than general tax revenues and this could be continued. Workers already pay FICA taxes to fund Social Security and Medicare. In addition, they pay health insurance premiums. Combining the two would allow some cross subsidy for the Medicare deficit we face in the next few decades as “Baby Boomers” retire.
The US has 50 states and there have been a few attempts to use states as “laboratories of democracy” to test health care reform experiments. These do not work (except, perhaps, for Hawaii, which is relatively isolated) because states are not large enough and people will move around to acquire benefits. Any real reform has to be national. What I propose is to move to a universal Medicare program which would pay 80% of health care costs. The co-payment would be paid by private insurance, just as is done in France. Costs would be subject to “Evidence-based Medicine” criteria for reimbursement. If people want chiropractic treatment or acupuncture or massage, let them pay for it without subsidy. This may, in fact, be the most difficult part of the problem to solve as our state regulation is highly politicized and influenced by lobbies of various health care organizations.
I would also strongly recommend that the Workers Compensation system be integrated into the health plan, as is done by France. I work with the Workers Compensation programs in multiple states, reviewing claims, and find that many of these workers have no private insurance. Integrating workplace injury treatment would avoid costly duplication and help reduce fraud, rampant in workers comp.
What do we do with illegal aliens ? They dominate public care in Los Angeles and fill emergency rooms of private hospitals. Since the Federal Government chooses to allow them to come into the country, they should pay for care of illness and injury. They are already eligible for workers compensation care.
What about nursing homes and treatment of the disabled? Medicaid is already the principle source of funding for care of the elderly and disabled poor. Integrating this into a national health plan would relieve a huge burden on the states and might reduce some of the gamesmanship in state-federal relationships.
What about a fee schedule, like that of France ? Doctors’ incomes have been eroding steadily the past 30 years as HMOs gained power and the FTC has prosecuted doctors’ groups for any attempt to negotiate fees with them. They should be allowed to represent members as a union and negotiate fees and terms. The Los Angeles County Medical Association has disappeared as members found themselves without the means to support it and it was dissolved with its magnificent library dispersed.
New doctors are heavily burdened with debt. USC medical school, where I teach, now has a tuition rate of $40,000 per year. The average medical student leaves with loan balances of $250,000. New young doctors must earn enough to repay loans. The problem has become so severe that a new medical school organized by the Cleveland Clinic and Case Western University has decided to grant 100% scholarships to all students accepted, in hopes of encouraging more to choose academic medicine. The military services offer full scholarships to medical students who agree to serve a minimum time as military physicians. What if we offered all new doctors, who agreed to accept the national fee schedule as payment in full (after co-payment), a full scholarship to medical school ? If later, they decided to shift to the equivalent of Sector 2 in the French system and charge higher fees, they would have to repay their scholarships. A system to forgive existing loans could even be introduced. Each year a new doctor participated in the Sector 1 equivalent, part of the loan was forgiven.
There are many permutations of a program like this and I offer these suggestions only for discussion. What about it ? One additonal advantage of a system like this is adminsitrative savings. Doctors offices have severe overhad problems trying to deal with the many HMO and IPA contracts plus Medicare paperwork. When I was in practice 13 years ago, I had 246 different contracts with various insurance groups, most with different requirements for pre-authorization and the like. I finally bought a computer system for the office to deal with the complexity. A card reader system like the carte vitale would be a godsend to doctors’ offices. The savings alone would make a lower fee schedule more acceptable. I know pediatricians whose capitation payment for HMO patients is no higher than the French Sector 1 fee. I am not an accountant but I think this could work. Something has to.
Health Reform – France III
Friday, May 16th, 2008How is reimbursement accomplished ?
The carte vitale changed a system based on paperwork to one with a very modern and efficient methodology. Prior to electronic billing, the patient had to obtain treatment or prescription forms called feuilles de soins from the doctor, attach any stickers (vignettes) from the pharmacist, which identify the class of drugs dispensed, plus a certificate from the employer (attestation annuelle), or a certificate of unemployment from the national office, and submit them all to the local CPAM. A few weeks later, a statement of amounts to be reimbursed would be received, followed eventually by the money. In 1998, 1.2 billion feuilles de soins were submitted.
If the doctor has the proper card reader (and in 2001 when the report was written, it was a problem), the card is swiped and the proper form goes electronically to the CPAM. Confidentiality is assured because a second card, issued to the doctor and called Carte Professionnel de Sante, or CPS, is required for transmission. Card holders have the right of access to the database where their records are kept by the CPAM.
In 1999, in response to a perception that 25% of French citizens postponed care due to financial concerns, and another 150,000 were still not covered, another system was added for the poor. Couverture Maladie Universale or CMU, now covers a million people who receive free care. There is CMU de base, which enrolls people who are not covered by NHI into CNAMTS and which covers all residents of France regardless of employment status. This provides free care. A second level, called CMU complementaire covers the supplement for those earning less than 3600 FF per month (as of 2001 before the Euro). This could be considered analagous to our system in which poor Medicare recipients are eligible for Medicaid payment of the deductable or co-payment.
Applicants must register at the CPAM and those eligible for CMU complementaire, may select a mutuelle to manage the co-payment. Once granted, the free care is valid for a year, after which the person must reregister. The person receives a carte vitale and the care is the same although they must select physicians from Sector 1 who accept the fee schedule (conventionne). Prescriptions, hospital care, some dental care and eyeglasses are included. CMU assurance complementaire covers 4.7 million.
British expatriates living in France can apply for CMU and the rules are described here. That site is one for advice to British retirees living in France and is interesting for other aspects of life in France.
The system is not foolproof as this message board for British retirees shows.
Here is more timely information about enrollment, again from the point of view of British retirees moving to France. This is a very large group and some areas in the southeast have completely English-speaking villages.
Providers
Free choice of doctor is assured, a feature of the French system that is very attractive to us as we are losing that very feature of the American system. The French can go to any doctor, can go to specialists directly without a “gatekeeper,” and can choose a public or private hospital. The private hospitals do not have to accept the government rates and generally require payment at the time rather than wait for the reimbursement from CNAMTS. Doctors may only advertise in “The Yellow Pages” and there is none of the marketing we see here. Health organizations and private clinics are allowed to advertise (some in the Paris Metro) and all doctors must post their fees. Patients are free to change doctors and seek second opinions. Appointments with GPs are 15 to 30 minutes and direct payment encourages the doctor to treat the patient as an equal, unlike HMOs in the US and NHS hospitals in the UK. Free choice of hospital is also the rule.
Fees
In 1997, 99.6 % of physicians were in Sector 1 or 2. Of these, 74% were in Sector 1, 83% of GPs and 62% of specialists. The Sector 1 physicians are contracted with the NHI and are paid from the negotiated fee schedule ( NGAP ), which is revised annually. By agreeing to the fee schedule, Sector 1 physicians become eligible for pension and sickness benefits. Sector 2 physicians may set their own fees but do not have the pension and sickness benefits. The additional fees, above the national fee schedule, are the responsibility of the patient. When this reform was established in 1980, Sector 2 became popular, especially with specialists, but initially only 7.5% joined Sector 2. By 1997, Sector 2 had 57% of physicians and access to the category was limited. This may have been the result of Sector 1 fees not keeping pace with inflation. In 1998, 51% of physicians were specialists (49% GP) and 75% of GPs were in private practice. Specialists were more likely to be employed by clinics and teaching hospitals but 68% were still in private practice. Many medecine liberale (fee-for-service) GPs are practicing in cabinets liberaux, a one physician office with a small staff. Group practices are more common in urban communities. Many GPs list themselves as medicins de famille or family doctors and care for entire families. The fee for one of these visits is quite modest, about 11 pounds sterling in 2001.
There is a gatekeeper-like system that is optional and is called medecins referent. The patient, by giving up the right of free specialist consultation, is rewarded with waiver of the co-payment and the physician receives the co-payment directly from the CPAM. GPs who agree to become medecins referent receive a capitation fee for each new patient. They must use generic drugs for 10% of their prescriptions and additional record keeping is required so only 13% of GPs have agreed to join. There has been considerable resistance from both GPs and specialists, who fear restricted referrals.
There are between 1,000 and 2,000 municipal medical centers with salaried physicans. They are operated by municipalities, trade unions, mutuelles (a remnant of pre-war medicine) and are important in caring for the poor. The institution of the CMU may affect these centers as Medicaid affected county hospitals in the US after 1965.
About 40% of doctors are union members and there are three unions; Confederation des Syndecats Medicaux Francais (CSMF), the pre-war organization; Federation de Medecins de France (FMF), a small federation which broke the resistance to the 1980 reform by signing up, and Medecins generalistes de France (MG-France). These were formerly professional associations but have become unions and are not averse to direct action when provoked. They negotiate fee schedules with CNAMTS each year and concern themselves with professional issues such as regulations and hospitals.
Hospitals
There is a daily hospital charge, forfait hospitalier , although patients may request direct payment for hospital care, called tiers payant, or “one-third to pay”. This is based on the ticket moderateur, a schedule of co-payments.
ticket moderateur — Co-payment based on Securite Sociale payment schedule
Consultation fee during hospital stay——-20 %
Hospital treatment————————— 20% most cases
Doctor’s fees (specialist and GP)————30%
Paramedic fees and lab fees—————– 35%
Medicines with blue vignette —————65%
Medicines with white vignette ————–35%
Vital or expensive drugs ———————-0%
Ease and comfort drugs (non-prescribed)–100%
Other expenses and transport—————–30%
Private hospitals may charge what they wish (although patients are reimbursed at the national rate) and payment is required at the time. All hospitals have a fixed charge per day, called taux/forfair journalier, which is a “hotel costs” charge for room, board, etc. US hospitals used to bill this way until the stupidity of insurance companies required itemized billing and set off wild inflation in hospital bills. Children, maternity patients and war veterans on pension are exempt from this charge. Advance approval for some services, such as dentistry, physical therapy and prosthetics is required.
Some cases are eligible for exemption for co-payment. Serious medical conditions such as diabetes, cancer and AIDS are exempt. The exemption pertains only to the diagnosis and other conditions require co-payment. A cancer patient with appendicitis, for example, must pay the regular rate for the surgery. More complex services and hospital stays over 31 days are also exempt. The exempt class of patients, such as children, maternity and war pensioners are the third category.
Types of hospital
Two thirds of hospital beds are in public hospitals. The Hospital law of 1991 gave the public hospitals autonomy and the larger hospitals and teaching hospitals are public. In 2000, there were 1,050 public hospitals with 323,098 beds (or 5.5 per 1000). They included Regional Hospitals, usually in cities and most have medical schools. There are 29 of these. Hospital Centers, which are in Department capitals, and hey tend to provide what we would call tertiary care, such as mental health or cancer treatment. Local hospitals are the third level and correspond to Level III hospitals in the US.
There are private non-profit hospitals, many of them specialized centers such as the 20 cancer centers. They tend to concentrate on long-term care and special care. They have similar rules and financing to public hospitals although staff membership may be restricted. In 1998, there were 24,782 beds in such institutions.
Private for-profit hospitals are mostly acute care and do a lot of surgery. Many are small although there has been a trend to consolidation. In 1998, there were 98, 813 beds in such hospitals and they have 20% of hospital capacity.
The public hospitals tend to have salaried doctors and France has a smaller proportion of hospital-based specialists than other European countries. Private hospitals tend to be staffed by fee-for-service specialists and the public hospitals have been short-staffed, often hiring foreign doctors to fill positions. Since there is no problem with delays and queues for care in public hospitals, the political issue seen in the UK does not exist in France. It is simply a matter of choice.
Hospital budgets have been under strain in recent years and, since 1984, have been under a global budget process. Since 1996, regional hospital associations ( ARH) have established budgets at a more local level based on need. France was the first country to adopt Diagnosis Related Groups (DRG) which became a controversial Medicare reimbursement reform in the US in 1986. Private hospitals sign contracts with the regional agencies, Schema regionale d’organisation sanitaire, or SROS. Private hospitals are paid on a combination of per diem and fee-for-service. They do not have a central budget like the public hospitals. All the hospitals, including the public institutions, are judged by patients on cleanliness and food quality. Semi-private and private rooms are the rule. There are no wards.
Emergency Services
Pompiers medicaux are the equivalent of paramedics with special training but are not at a level with physicians.
Service d’Aide Medicale Urgente (SAMU) is an ambulance service that is in radio contact with physicians and may involve physicians in the ambulance. There is a high hourly charge that is waived if the patient is admitted to the hospital. If they do not go to the hospital, they are responsible for the copayment of 30%. If they are not a member of Securite Sociale, they are responsible for the entire fee. If they have a mutuelle, it may pay the co-payment. American trauma physicians have been critical of the care of Princess Diana because the ambulance team remained on scene for over 30 minutes before deciding to transport her to the hospital. This may be a feature of SAMU care, which does often treat patients at the scene. American trauma care strongly supports the protocol of “scoop and run,” which discourages any attempt to stabilize a patient at the scene of an accident except for airway management.
Pharmacy and laboratory
Pharmacies are on every corner in France. Reimbursement requires a doctor’s prescription and is determined by the color of the vignette unless it is a “vital” drug. Both Securite Sociale and mutuelles provide payment so much of the cost may be covered for prescribed drugs. Approval of drugs is through Objectif National des Depenses d’Assurance- Maladie (ONDAM), a national agency, and Commission de la Transparence. There is price regulation although France has always had an excellent pharmaceutical industry. Spending targets are set and penaltes may be levied for violation.
Laboratoires are private and are recognized by display of a blue cross. Results go to the patient, not the doctor, to assure free choice.
French consumption of health services is the highest in Europe. In a 1998 survey of 23, 035 persons, chosen by household, 33% had visited a doctor at least once in the previous month, 19% a GP, 8% a specialist and 6% both. In 1994, mandatory practice guidelines (see my post on Evidence-Based Medicine), were introduced. They are called References Medicales Opposables (RMO) and are mandatory although an attempt to fine doctors for violating them was ruled unconstitutional. In 1998, use of RMOs resulted in a health spending budget below projectons and a “bonus” was provded to GPs. It was protested by the medical associations for rewarding provision of less care but I don’t know if anyone refused to accept it. The same method is often used by HMOs to reward compliance with guidelines for utilization.
Implications for US reform
I have never been a patient in the French medical care system. I do know that French surgery is of the highest quality and the entire laparoscopic surgery movement originated there and in Germany. In 1987, Eddie Joe Reddick, a Nashville surgeon and good ol’ boy, was vacationing in Paris with his wife. Bored with museums, he got permission to observe surgery in a Paris hospital. What he saw revolutionized American surgery. He returned and got a friend, Barry McKernan, to teach him laparoscopy. Within a year, surgeons were taking laparoscopy courses, many from McKernan (as I did in 1988), to learn the new technique. In 1992, I attended a laparoscopy meeting in Bordeaux to learn the newest techniques which were still coming from French surgeons. They have remained at the forefront of world medical advances.
The French system has many similarities to our own. It is complex but the components are similar to those of our own system and that fact may permit integration of gradual changes and allow alteration to respond to problems. The basic reform in France was the Securite Sociale, similar to our Medicare program in 1965. One of the proposals for reform has been to adapt Medicare to the entire population. One way to do this would be to use the existing health insurance industry as the French use the mutuelles, to handle copayment and administration. Health insurance in the US is not really insurance. Employers use insurance companies to administer self-payment programs. Insurance companies have become “administration service organizations.” This is not that much different from the non-profit CNAMTS, which has a board composed of employers, unions and physicians. One difference that may be necessary is to get rid of the adversarial role of the Federal Trade Commisson toward doctors and their organizatons. Any fee negotiation has been banned for 30 years and that inhibits any attempt to deal with for-profit HMOs which are destroying the medical profession, especially in California were they are triumphant. Poor care and bankruptcy for medical groups has been the legacy of for-profit HMOs.
The use of the electronic carte vitale alone would reduce overhead for medical practices by 75%. Estimates of costs of administration for American medicine probably exceed the entire budget for French healthcare. The French have been having problems with cost but much of that comes from factors unrelated to health care, such as the 35 hour work week and the cost of unemployment which discourages employers from adding staff. With a more vibrant economy, the cost of the French healthcare system would be far less than our own as a percent of GDP, and would relieve the burden on manufacturers. Unions would probably resist letting go of their health plans that they administer and have a sense of entitlement to since they were often the trophy of negotiation and even strikes.
Straight single payer with no co-payment, like the Canadian system, will never work here. We are not a people who will accept queues and overt rationing. The French system looks enough like our own that a transition would be less painful and could be gradual. It already has the Medicare basic format that it shares with Securite Sociale.
Health Reform- France II
Thursday, May 15th, 2008Since 1958, France has been ruled by The Fifth Republic, a democracy with a strong President. It was essentially designed to suit President De Gaulle when he assumed office to resolve the Algerian Crisis. This left France with a very centralized government, a “unitary system of government,” without the states we have or the provinces of the Ancien Regime that ruled France before the Revolution. The Legislature is bicameral with a National Assembly of 577 Deputies directly elected, and a Senate of 321 members indirectly elected and with less power. Deputies of the Assembly serve five years and Senators serve nine years.
Since 1986, the health care system, Securite Sociale, has been decentralized to 22 regions, each with an elected local advisory council. Policy comes from Paris but there is considerable local control. France also has 96 Departments with elected councils, which select a mayor with some public health responsibility.
Hospitals are both public funded, two thirds of them, and private, about half nonprofit but some for-profit. Everyone who is employed in France must join the Securite Sociale and must contribute to the system which has four branches; sickness and maternity, death benefits, invalidity insurance (disability), work accidents, old age and family. It is interesting that Britain, with its unitary NHS, also has a separate workers compensation health system like that in the US. The unions were unwilling to give up this fiefdom when the NHS was founded. We can expect similar resistance from unions to reforms that involved union health plans. France has successfully integrated them.
The entire system is called Natonal Health Insurance, or NHI. The largest system, covering 80% of the population, is Caisse Nationale d’Assurance Maladie des Travailleurs Salaries (CNAMTS), which includes all salaried workers and their families. The system is administered by 16 regional funds and 133 local funds that are self-governing with a board made up of employers and unions. There are 17 other funds covering by occupation such as agricultural workers, civil servants, medical doctors and students. A registration card is issued to each member and is called carte vitale with a registration number. More recently, these cards are embedded with information about coverage, such as the co-insurance, and are read by a card reader in the doctor’s office. There are criteria for membership, including hours worked or contributions made.
Since a 1996 Reform, the parliament has set a budget and the Health Minister chairs a High Committee of Public Health, which sets policy. There is a National Health Conference and Conferences Regionales de Sante, which set local objectives. The 22 regional bureaux are called DRASS, a French acronym, and monitor the regional budgets and hospital construction. We have something similar called Health Planning Agencies that used to issue “Certificate of Need” for new CAT scanners and the like.
French residents register at the local office of CNAMTS, called CPAM or secu of CNAMTS. The secu is responsible for benefits and claims. The regional offices are called Caisses Regionale d’Assurance Maladie, or CRAM, which deal with occupational injuries and social programs. Another agency called Unions Regionales des Caisses d’Assurances Maladie or URCAM, deal with social insurance administration. In 1999, France spent 9.4 % or GDP on health care, high for Europe but well below our own expenditures. These Caisses are actually non-profit agencies that are not part of government but are funded by the payroll tax. They are governed by boards including employers, unions and one-third doctors.
A new (2000) social security tax (Contribution Social Generalisee – CSG) was introduced to relieve some of the burden on employment taxes. Supplementary insurance (analagous to our Medi-Gap policies) is provided by three types of organizations. Provident societies (like fraternal organizations), mutual funds (which provided all health insurance prior to 1945), and commercial insurers. There is a great variety of such plans, some group plans tied to professions for example. They provide a small fraction of hospital care but about 10 to 15% of ambulatory expenses, including drugs. This has allowed the French to avoid rationing as those who can afford it, prefer to pay the premiums. In 2001, 87% of the population had such insurance.
The basic principle of French healthcare is avance de frais, or payment directly from patient to doctor. The freedoms of personal payment, freedom to choose a doctor and the doctor’s freedom to practice, are fundamental to the French system. The patient is reimbursed by insurance, 80% by Securite Sociale, and the rest by assurance complementaire but the principle is supported by the French when they are surveyed and they are suspicious of “free care” as wasteful and liable to abuse.
to be continued:
Health Care reform- The French system I
Wednesday, May 14th, 2008I have been reading a book about the origins of the French health care system, comparing it to the history of our own. Another excellent source, with more on the contemporary program, is here. The latter source compares the British NHS with the French and German systems. One statistic stands out. In a survey of users, 56% of the British surveyed believed their system was so bad that it should be scrapped and they should start over.
The French system evolved over the past century in a fashion very similar to ours. They emphasize private, fee-for-service practice even more than we do. In the 1930s, the French instituted a system quite similar to our Medicare system although it covered wage earning workers, not the elderly. For those workers, it was mandatory although it initially did not cover “white collar” or agricultural workers. The French had traditionally bought health insurance from fraternal associations, just as we did prior to the Second World War. In 1930, the unions (chiefly the CGT) were the force pressing for compulsory insurance. The doctors had split into three groups on the issue. Finally, a centrist named Paul Cibrie, founded a new group called “Confederation des Syndecats Medicaux Francais (CSMF) and carried the majority into approval of a compromise that established a “medical charter” for doctors, guaranteeing fee-for-service medicine and free choice of physician for patients. That charter has continued to this date. It included direct payment of fees, freedom for the doctors to set fees, and confidentiality. The mutual societies were included in their role as intermediaries, although government oversight was included. The 1930 French system was funded by payroll deductions. In the US, adamant opposition by the AMA prevented any compromise until the Medicare legislation in 1965.
In our case, the War brought the employer-based system we have for two reasons. One was that wages were frozen during the war but fringe benefits, up to 5% of wages, were allowed. Provision of health care allowed employers to attract scarce labor during the war. The other was that it was tax exempt while private insurance was not. Many of the health benefits were the result of collective bargaining so unions, which often administer their own plans, have been very reluctant to adopt any alternative. Both Harry Truman and Bill Clinton learned that Democrat Presidents got no cooperation on that subject from unions. Both had plans for major reform that didn’t happen, largely because they got no union support.
The French had a very different experience. In 1940, Germany defeated the larger French Army in a lightning six weeks campaign. The occupation and Vichy rule displaced all of the traditional forces in French society, including the medical association leadership. The Vichy state even appointed a new medical society, called “Order of Doctors,” after it abolished all professional organizations and independent unions. The new society, headed by famous surgeon Rene’ Leriche, urged conformity in a time of crisis. Vichy had some ideas of its own, such as a German-like emphasis on the role of women as home makers and mothers. New maternity clinics were founded and hospitals were opened more to the general public. Low population growth, after the catastrophic loses of men in World War I, was blamed for defeat even though the French Army was larger than the German in 1940 and had better equipment.
Meanwhile, the Free French groups in exile in England planned for the post war period including health care and pension reform. I found it interesting that they were so concerned with such matters at such a time. The 1930s had been a period of labor unrest and this was also thought to be a factor in the French weakness in 1940. The committee that worked on Securite Sociale included labor leaders from CGT and Pierre LaRoque, who had served briefly as a Vichy Labor Minister until his Jewish origins led him to emigrate to England. In the 1930s he had played a large role in the Labor Ministry under several governments. With the 1944 invasion, German authorities warned French doctors not to treat wounded Resistance members but the President of the Ordre des Medicins courageously contradicted the German orders and encouraged doctors to treat everyone and ignore the orders to report them to the authorities.
With the end of the War, France made a leap into the future with the founding of Securite Sociale, a program of health care and pension benefits that remains the basis of the French system today. Private fee-for-service practice was preserved and, after disputes arose about fee schedules, DeGaulle himself, intervened in 1960 to demand that doctors accept a uniform fee schedule. He said, “I saved France on a colonel’s salary !” The doctors signed up.
In early 1945, LaRoque became head of Securite Sociale and, even though he was subordinate to the Labor Minister, his relationship with De Gaulle gave him great power. Many large employers (Not including Marcel Michelin) had collaborated with Vichy, weakening their influence, and the mutual societies, which would lose their major role as intermediaries once the government assumed the primary role of administrator, eventually found a role as providers of “gap” coverage. Here too, the mutuals lost influence because they had collaborated wth Vichy. The upheaval of the war allowed much more radical reform than was possible in the US. Roosevelt briefly considered inclusion of health care in the Social Security Act but it never found support.
The Securite Sociale boards were dominated by union officers as employers lost influence. Doctors retained their influence because they had not collaborated and they quickly reconstituted the CSMF. The local syndecats, equivalents of our medical associations, assumed a major role in setting fee schedules and adjudicating disputes. One third of the seats on the boards of Securite Sociale were reserved for physicians. Fee-for-service medicine was preserved in the interests of freedom, both for doctors and for patients. Doctors resisted payment by third parties and patients paid the bill and then sought reimbursement of 80% from Securite Sociale. This was a wise decision as it tended to dampen the moral hazard problem that has bedeviled the US system. Even today, (more of that later) patients, except in expensive procedures, pay the doctor directly and get reimbursement from the plan.
The British of course, went another way with the NHS and a total tax-paid system. The French system, like that in the US, was funded by employers and workers through payroll deductions. The French system was funded from a 16 percent deduction from wages, ten percent paid by the employer and six percent by the worker. The contribution is now up to 20 percent and there is serious resistance to any increase. The deduction, like our FICA deducton, funds pension and unemployment, as well as health care. There were still some government clinics but the basis was private care. Unions and employers sat on the board of the government program, although employers had less power than before the war. The fee schedule was to be set and the Securite Sociale payment would be 80% of the fee, just as Medicare was expected to pay only 80%. In both countries, private insurance quickly appeared to fill the gap and defeat some of the purpose of the deductable. In the US, Blue Cross and Blue Shield stepped in with “Medi-Gap policies; in France, it was the mutual societies which had been pushed out of health care insurance by the government program in 1945.
The original French plan in the 1930s was to cover lost wages during illnes, as actual medical costs were small. After the war, as hospitals grew and more were built in both countries, medical costs outpaced the lost wage segment, covered in the US as unemployment insurance, not health benefits anyway.
In both countries, “Usual, Customary and Reasonable” fee schedules were the Achilles heel of private fee-for-service medicine. How the French solved this problem, to the extent they have solved it, is the major lesson of the comparison. Gradually, Securite Sociale covered greater and greater portions of the population until now 99% are covered. The government pays for those who do not earn enough to contribute and Couverture Maladie Universelle (CMU) determines how much the member must pay. Above a certain income, the member pays their own way for the 20% (or more like 30% now) that is not covered by the Securite Sociale. In 1958, a survey of members asked “Should the healthy pay for the sick or should everyone get back only what they put nto the system?” 86% answered that the healthy should pay for the sick and 95% approved of the compulsory nature of insurance even though complete coverage of the population, including agricultural workers, came only in 2000.
The most significant difference was that, in France, the private insurance companies provided the “gap” coverage and the government program provided 80% of the payment. In the US, except for Medicare and Medicaid, it was all private. The book comments that French doctors have lesser incomes compared to US doctors but French medical school is free and US doctors might well choose that over the huge student loans they must repay the past 20 years. The makings of a grand bargain might just lie in that difference.
The French citizen or resident joins Caisse Nationale d’Assurance Maladie deTravailleurs Salariés (CNAMTS)—health insurance organisation for salaried workers. That covers about 80% of the population now and it pays 80% (often more like 70%) of a fee schedule for the doctor visit although specialists are allowed to charge more. French doctors are divided for payment and fee schedule purposes into three “sectors” after 1980. Sector 1 doctors agreed to abide by the fee schedule established in 1960, modified for inflaton and technological changes. They are mostly primary care doctors although some had waivers from the fee schedule prior to 1971 because they were more experienced or had great reputations. Few are still practicing. Sector 2 doctors could set their own fees but reimbursement was still determined by the fee schedule. These two categories correspond roughly to Medicare assignment in the US. If you accept assignment, you agree to accept Medicare payment as the full payment (or 80% of it plus the Medi-Gap payment) . Those who refuse to accept assignment may set higher fees but the patient is not obliged to pay more than the “allowed” charge. The French system is similar. Sector 3 in the French system is very small (about 1.5% of doctors) and includes “Alternative Medicine”, for the most part. They do not participate in Securite Sociale payment.
To be continued.
The National Vaccine Injury Compensation Program has lost its bearings
Wednesday, May 14th, 2008There was a recent flurry of interest in the fact that a government program “admitted” that vaccines may be related to autism. This article explains why that is and suggests that the VICP has gone off the reservation and is now accepting non-scientific input. That is very bad news when measles epidemics are returning for the first time in 30 years and a school has to close because of whooping cough. Children are going to die because of this nonsense.
Jihad on Jihad
Tuesday, May 13th, 2008The Department of Homeland Security has taken leave of its senses and now wants to convince us that Islam is not related to terrorism. The Half-Hour News Hour had a show recently that must look like that DHS meeting where they came up with this policy.
The manual life
Tuesday, May 13th, 2008When I applied for a surgery residency, only one professor asked me questions about my manual dexterity. He asked if I played a musical instrument (I had but not well) and whether I worked with tools. I had been working with tools since I was a child. One of my earliest memories was smashing my thumb with a hammer. When I was a medical student, we had real labs. In Physiology and Pharmacology we would inject rabbits with drugs and measure the effect. Sometimes we constructed preparations with a frog’s leg and its nerve. Sometimes it was a heart beating in a dish of nutrient solution.
In recent years, some students have begun to complain about the use of animals in research and in biology labs. The lab benches have disappeared from medical schools. Students don’t even use microscopes anymore. I wonder if an applicant to a surgery program is asked about manual dexterity now.
This essay discusses the disappearance of shop class in high school (my Catholic high school didn’t have shop) and the decline of the manual arts as vocational choices. A Mercedes mechanic can earn $150,000 a year in a dealership position but college graduates earning 14 dollars an hour will look upon him as a “blue-collar worker.” The essay points out that many of the people described in the book, “The Millionaire Next Door” are in fact the products of such technical trades.
It has been said that India was for many years held back in its development because the British educational system had left a tradition of contempt for such manual trades. India had plenty of doctors but few auto mechanics. I wonder if we are headed the same way?
Is it too late for sense on climate change ?
Monday, May 12th, 2008This letter suggests that the UN reconsider its approach to climate change. After all, the climate has been changing as long as there is any evidence to study about earth temperature. In 1200, Greenland supported farming and a population of 5,000 people. With the onset of The Little Ice Age (Note that Wikipedia is not reliable here for reasons previously explained. They even still have the “hockey stick.”), the Norse population died out and was replaced by Inuits who arrived about 1200 AD and remain the Greenland population. They were better able to tolerate the Arctic conditions that followed.
The Bush Administration seems to have given up on this subject, seemingly planning to run out the clock, and McCain may be too willing to be influenced by the climate-politicians. We’ll see.