September 14, 2009

Health Care in Other Countries: France

New York Times "Prescriptions":

Victor G. Rodwin is a professor of health policy and management at the Wagner School of Public Service at New York University and co-director of the World Cities Project, International Longevity Center-USA. He teaches courses on health system comparisons and has widely published on the French health care system. He spoke with the blog contributors Sarah Arnquist and Anne Underwood.

  • Life expectancy: 81 years (USA: 78)
  • Infant mortality: 4 per 1,000 live births (7)
  • Health spending as a percentage of GDP: 11 (15)
  • Percentage of health spending that is private: 20 (54)
  • Doctors per 10,000 people: 34 (26
Source: World Health Organization.

Q. In 2000, the World Health Organization ranked the French health system as the best over all in the world. Do you agree?

A. I question the W.H.O. methodology, which has serious problems with data reliability and the standards of comparison. A study I would take more seriously is one published last year by Ellen Nolte and Martin McKee in the journal Health Affairs. They examined avoidable mortality — that is, deaths whose risk of occurrence would be far lower if the population had access to appropriate health care interventions. In that study, based on data for the year 2000, France was also ranked No. 1, with the lowest rate of avoidable deaths. The United States was last, in 19th place, with the highest rate of avoidable deaths. That’s a severe indictment of our health care system in my judgment and calls attention, quite justifiably, to the high performance of the French health care system.

Q. That finding implies that the French have good access to health care. Do they?

A. On most measures, they do. They don’t do a better job of cancer screening than we do. But when it comes to timely access to primary care, the French are superb.

An important and well-recognized measure is avoidable hospitalizations. People should not end up in the hospital for failure to manage routine, controllable conditions such as asthma, bacterial pneumonia, diabetes or congestive heart failure. Based on studies with my colleagues Michael Gusmano and Daniel Weisz, the United States has exceedingly high rates of avoidable hospitalizations compared with Britain, Germany or France. Comparing Paris and Manhattan, we have 2.5 times the rate of avoidable hospitalizations that they do in Paris.

Moreover, when it comes to specialty care, the French also have ready access. For example, my colleagues and I found that contrary to conventional wisdom, the French provide higher rates of bypass surgery and angioplasty than we do.

Q. As I understand the French health care system, doctors are private, but patients are enrolled in national health insurance. Is it sort of like Medicare for all?

A. Very much so. It’s not government run but government financed. Like Medicare and Social Security, it is funded by compulsory payroll taxes with some income tax contributions. But doctors work predominantly in private, office-based, fee-for-service practices, and there is a mix of public and private hospitals. The main difference from Medicare is that the entire resident population is covered and the benefit package is more generous.

Almost the entire population has some degree of private supplementary insurance, too, much like Medigap policies for Medicare beneficiaries in the United States, to provide better coverage for certain services and to cover a portion of co-insurance.

Q. So it’s not a single-payer system.

A. That’s correct, but it operates much like one. In France, nobody has a choice of insurer for basic coverage. There are three major plans — one for most people who are employed (77 to 78 percent of the population), a smaller one for agricultural workers (4 to 5 percent), and another small one for the self-employed (6 to 7 percent). In addition, there are some very small plans — for railroad workers, the clergy and so forth. But all of these health insurance programs operate under the same rules. Like Medicare, they can’t turn you down for preexisting conditions. They can’t terminate you if you change your job. And they can’t stop paying when your expenses exceed a certain amount.

Q. If the French system resembles Medicare, does that mean that it also faces the problem of rising costs?

A. Yes, all health care systems face the pressures caused by expensive new medical technologies and prescription drugs. Since there are no enforceable budget ceilings on French national health care expenditures, annual increases tend to exceed spending targets, which in turn leads to frequent cries that the system is “unsustainable.” Nonetheless, the French do a better job of controlling health care costs than we do. They spend about half as much per person on health care ($3,200), and spending accounts for 11 percent of the French gross domestic product, versus 17 percent in this country.

Q. How do they control health care costs?

A. Three ways. First, the government negotiates prices for doctors, hospitals and prescription drugs. Second, France has far fewer private health insurers, so the system requires less expenditure on administrative costs for marketing, underwriting and managing complex reimbursement rules. Third, France’s investor-owned insurance sector is far smaller than in the United States, and its medical-industrial complex is far less powerful, so the government can negotiate stronger cost controls.

Q. But you also said the French have no choice in their plan. Americans seem to want choice.

A. The French have no choice among insurers for the basic plan. But French National Health Insurance gives them more choice of doctors and hospitals than the average American has.

Q. Does insurance cover the entire cost of an office visit, or are there additional charges?

A. There are no deductibles. French National Health Insurance typically pays 70 percent of an office visit. A G.P. typically charges the patient 30 percent of the $35 fee, and a specialist will charge 30 percent of the $45 fee. But co-insurance is waived for all patients with serious chronic medical conditions such as asthma, diabetes, cancer, heart disease or any other medical condition requiring more than $100 per month in payments.

Most physicians in private practice accept negotiated N.H.I. fees. However, in large cities and for most subspecialties, 50 percent to 80 percent of physicians have chosen to “extra bill.” These physicians must pay higher premiums for their own health insurance coverage (as subscribers of the fund for the self-employed). Most of their patients can use their supplemental policies to cover some of these additional costs. But such extra billing does create hardship for people with few resources, who forgo seeing these specialists and must therefore go to hospital outpatient departments or to health centers. That’s one of the big issues now.

Q. Are the insurance companies nonprofit?

A. All health insurance funds that provide benefits under the national plan are legally private nonprofit organizations. The companies that provide supplemental insurance are a mix of for-profit and nonprofit entities. But they represent only 8 percent of total health care expenditures. It’s a smaller industry because benefits under French N.H.I. are extensive. Prescription drugs, for example, are covered exceedingly well. What’s not covered well is dental care and vision care.

Q. Is there rationing of care?

A. There is no explicit health care rationing in France. There are no waiting lists for specialized hospital treatments. There is very easy access, perhaps too easy, to specialized services. An important characteristic of the French system is that the sicker you are, the better you’re reimbursed.

Q. What does the French system do particularly well?

A. They have great access to primary care. In addition, they make specialty care available to anyone needing it. They have excellent prescription drug coverage, and they give extraordinary choice and freedom to people to navigate the system as they see fit.

Q. What’s your the biggest criticism of the French system?

A. There is poor care coordination between general practitioners and specialists, and also between hospitals and patients who move into ambulatory care. It’s a problem for people with chronic diseases.

Q. Medical malpractice has become an issue now in the debate over health care reform in this country. How much of every health care Euro in France goes to pay for malpractice costs?

A. I’ve never seen such an estimate, but even in the U.S. this figure is much smaller than people generally believe — less than 1 percent of health care expenditures.

Q. Doctors in the United States complain about having to practice “defensive medicine,” ordering unnecessary tests just to cover any potential charges of negligence later on. Is that an issue in France?

A. No, this is not an important issue in France for two reasons. First, since 2002 there has been a national no-fault compensation scheme. Second, the number of attorneys per capita in France is far smaller than in the United States.

Q. Have the French achieved universal health care?

A. Yes, the entire population legally residing in France is covered — more than 99 percent of the population. There are always people who fall through the cracks. But they are covered under a special plan that covers people whenever they show up at the E.R., the hospital outpatient department or health center.

Q. Are the French happy with their health care system?

A. Eurobarometer, Harris Interactive and other studies of consumer perceptions have consistently reported high rates of satisfaction among the French — among the highest in the European Union and certainly higher than in the United States. Still, my French colleagues were surprised when the W.H.O. report came out, ranking their system No. 1, because they are typically critical of their system. I don’t know any health system about which you can’t tell a horror story that occurred to a patient. That’s why it is so important to avoid cocktail party anecdotes of health system performance and rather examine evidence in a more systematic fashion.

Q. What key lessons can the United States learn from France?

A. The French health system demonstrates that it is possible to achieve universal coverage without a government-run system that regulates how doctors practice medicine. In fact, U.S. physicians should note that their French colleagues are not constrained by private managed care insurance plans and have greater clinical autonomy.

The French system also demonstrates that in contrast to some single-payer systems, universal coverage does not preclude the existence of private insurers. In France, there’s a whole private insurance sector — not enormous, but big enough — and that’s important for the insurance industry to recognize.

By Anne Underwood and Sarah Arnquist
September 11, 2009