French Health System Research Articles

Les trompe-l'œil de la « gouvernance » de l'assurance maladie

<titre>Trompes-l&#8217;&#339;il in the &#8220;Governance&#8221; of Health Insurance French-German Contrasts </titre> The authors judge the relevance of the term governance &#8212; now the accepted term for the transformation of the regulation mode of the health insurance system &#8212; in relation to two basic issues&#160;: the horizontal relationships between state and non-state actors, and the importance given to negotiation between multiple actors. These two aspects of the system are then discussed in the framework of an analysis of the recent reforms in the French health insurance system. Finally, a comparison with Germany shows the limits of a governance unable to question the validity of the two essential elements constituting the identity of the French health system&#160;: the patient&#8216;s freedom and the freedom of liberal practitioners (doctors practising outside the state healthcare system).

Poor management of diarrhea in children in France

Every year in France infant diarrhoea is responsible for the death of 50-80 children under the age of 5 and the hospitalization of approximately 50,000 children principally related to the deshydration which it causes. A significant number of these deaths and hospitalizations could be avoided by simple measures aimed at preventing dehydration, measures which have been codified and internationally promoted by the WHO for the past 25 years. In France, a large number of physicians do not yet apply them; they do not prescribe oral rehydration salts in case of infant diarrhoea, but prescriable antidiarrhoeal drugs which are ineffective on dehydration and are formally rejected by the WHO in these cases. Looking through the prism of this collective failure, one can identify the various causes which put into question the entire French health system: Lack of epidemiological observation; Lack of targeting health actions and initiatives towards children; Insufficient medical culture; Very ambiguous relationships between the state and the pharmaceutical industry; System of continuing medical education strongly linked to the pharmaceutical industry and incapable, to date, of raising up the challenge of a change in practice, which is nevertheless necessary.

Report finds French health system on threshold of collapse

Report finds French health system on threshold of collapse

Opiate maintenance with buprenorphine in ambulatory care: a 24-week follow-up study of new users

Background: Many studies suggest that buprenorphine, a long acting partial opioid agonist, may be comparable to methadone in efficacy, with fewer withdrawal symptoms and a lower risk of overdose. The aim of this study was to assess the patterns of buprenorphine prescription use in ambulatory care and retention rate under treatment during a 24-week follow-up period. Methods: This observational cohort study included buprenorphine users identified from the French Health System prescription database in an area of 1 million inhabitants and followed for 24 weeks. Results: We selected 282 users of buprenorphine defined as “new users” (74% male, mean age 32.4±6.2 years). Three groups were defined: 50% of “rational users” (141 subjects, no more than 2 prescribers), 24% of “occasional users” (67 subjects, less than 2 buprenorphine prescriptions) and 26% of “non-rational users” (74 subjects, 3 or more prescribers). The overall 24-week treatment retention rate was 37%. Misuse of buprenorphine or benzodiazepines was significantly more frequent in “non-rational” than “rational users”. Conclusion: The retention rate with buprenorphine estimated in this observational study was very similar to that obtained in controlled trials. A majority of regular users of buprenorphine could be regarded as “rational users” in this area of France.

The health care system under French national health insurance: lessons for health reform in the United States.

The French health system combines universal coverage with a public-private mix of hospital and ambulatory care and a higher volume of service provision than in the United States. Although the system is far from perfect, its indicators of health status and consumer satisfaction are high; its expenditures, as a share of gross domestic product, are far lower than in the United States; and patients have an extraordinary degree of choice among providers. Lessons for the United States include the importance of government's role in providing a statutory framework for universal health insurance; recognition that piecemeal reform can broaden a partial program (like Medicare) to cover, eventually, the entire population; and understanding that universal coverage can be achieved without excluding private insurers from the supplementary insurance market.

Quel système de santé à l'horizon 2020 ? Présentation du rapport sur l'avenir du système de santé français

The development of frameworks for public services gave rise to an overall consideration of the development of health services across France over a twenty year period. Considerable attention is given to a prospective analysis of the issues to be faced by our health system over the next 20 years and of their territorial aspects. The summary presents a synthesis of the currently recognized factors and possible scenarios for: -the changing economic context and social safety net, -the evolution of needs, -dynamics of supply. The report's proposals to enable the French health system to adapt to these changes revolve around four main aspects: -the space of health services, -prevention and health promotion as an overriding priority, -organization of health services, -the system's capacity to adapt and evolve. Finally, the report examines the assessment of the implementation of the health services framework.

Economic Evaluation of Enoxaparin vs. Placebo for the Prevention of Venous Thromboembolism in Acutely Ill Medical Patients

Objectives This paper presents an economic evaluation of a strategy of thromboprophylaxis in acutely ill medical patients with enoxaparin 40 mg vs. no intervention in the context of the French Health System. Methods The evaluation used a decision-analysis model to simulate the results of a hypothetical naturalistic, long-term study reflecting the usual care pattern for the patients. The short-term outcomes were derived from an international, double-blind, placebo-controlled randomized clinical study performed in 1102 patients older than 40 years. Treatment was scheduled to last 10 ± 4 days and primary outcome was venous thromboembolism events rates between days 1 and 14 assessed clinically or through systematic contrast venography. Results For an hypothetical cohort of 1000 hospitalized medical patients, the model suggested that the prophylaxis strategy would avoid between 1 and 10 deaths (median 4) and between 60 and 127 cases of venous thromboembolism events (median 94). By including or not the costs associated with long-term complications (post–phlebitis syndrome), the net extra cost per patient was estimated as a net saving or 35,857 Euros (€), respectively. The corresponding cost-effectiveness ratios in terms of cost per avoided death were a net saving or €8102 (median value), respectively. Conclusion Thromboprophylaxis with enoxaparin in hospitalized acutely ill patients over 40 years of age appears to be an efficient strategy using French cost data.

Equity of a health system

Background: This study of the equity of the French health system is based on the principles which led to its creation from 1945 onwards. Efforts have been concentrated on the general implementation of health insurance for the whole population and the construction of a network of public hospitals to cover the territory. Methods: As far as equality of access to care is concerned, the results obtained during the 1990s show some positive effects of increased supply of hospital and community health care. However, inequalities between income groups with regard to community health care have increased and the choice of better performing hospitals by certain population groups favours the more privileged. Furthermore, interregional inequalities in the distribution of sickness benefits are considerable and did not decrease during the early 1990s. Results: These results indicate that the emphasis placed on accessibility over the past 50 years is not sufficient to ensure equity in the use of care and all the more so in health. Conclusion: The lack of connection in public policies between the priorities of health care and the distribution of resources remain among the major challenges that the 1996 reform is attempting to meet.

Internal medicine in France: past, present, and future

Internal medicine is a rather young medical specialty in France. Its growth has been a difficult one. There are about 2000 internists in France, the majority of them working in hospitals. The training in internal medicine takes 5 years. It is the longest training of all the medical specialities. Qualified internists may acquire an additional subspecialty in oncology, geriatrics, immunology, vascular medicine, infectious diseases, nutrition and metabolism, or intensive care medicine. In private practice, internists often examine patients referred by other doctors. In hospitals, the spectrum of the internist’s work is wide and depends on local needs. In universities, internists play a major role in the training of medical students. There are two national organizations of internal medicine: a scientific society and a professional syndicate. They work together very closely on matters such as initial and continuing education, congresses, defense, promotion of the specialty, etc. The place of the specialty in the French health system is now generally acknowledged. The Society has succeeded in organizing two national congresses each year; however, efforts are still necessary to improve public awareness of the usefulness of internal medicine and to increase the recruitment of young internists.

Evaluation comparative des services et structures de soins hospitaliers: Présentation du projet de la CNAMTS et application aux services d'urgences

There are different ways to compare hospital units for different purposes: financing, planning, facilities regulation, and the availability of public information. Most of these comparisons are based on administrative data and they do not take into account the point of view of the professionals and the theoretic framework provided by the agency relationship model. We present the French health insurance project for comparing and assessing hospital emergencies. We used the general framework of the French health insurance comparison project. A first panel had to select items for comparisons and assessment, considering different types of criteria (resource, process and outcomes) and the meaning of their use. Data collection had been tested on a regional basis and analyzed, providing a second items selection. Then this was compared with the literature and checked by the scientific society, determining the final data collection form. We present the final data collection form for emergency wards and the main trends of its analysis. This is the first attempt to provide for the French health system an integrated evaluation form for the comparison of emergency wards with respect to professionals' opinion. Its actual use and evolution will determine the global success of this work.

Background Paper: The quest for quality in primary healthcare in France - a Nordic view

Several interesting developments are taking place in general practice in France. One of the new elements contributing to change is quality assurance. The Norwegian author spent the academic year 1997-98 in Paris, working one day a week at the State Agency ANAES (Agence Nationale d'Accréditation et d'Evaluation en Santé - National Agency for Accreditation and Evaluation in Health). General practitioners working part time in the ANAES Department of Liberal Medicine are currently organising regional networks of GPs throughout the country to coordinate quality assurance activities. GPs are also involved in the agency's production of clinical guidelines. In addition to ANAES, several GP organisations are active in different aspects of quality development. The article looks at quality assurance as part of a new and more important role of general practice within the French health system, with some reference to simultaneous developments in Northern Europe.

Managing a pluralist health system: the case of health care reform in France.

During the last decade increasing health care expenditure led to persistent difficulties in the financing and management of the French health care system. A series of cost-containment measures in the 1980s and early 1990s concentrated on raising patient contributions and establishing global budgets for public hospitals. These initiatives met with limited success and did not address the issue of hospital management. In 1991 new reforms were instigated to strengthen the public sector and achieve a better balance with the private sector. Although these reforms altered management practice within public hospitals, they failed to tackle the underlying problems of the long-term financing and management of the French health system, ensuring continuing attempts at reform. The French experience provides evidence of the difficulties of reforming a pluralist health system that contains few incentives to stem rising expenditure.

The Divided Path: The German Influence on Social Reform in France after 1870

With The Divided Path, Allan Mitchell completes his superb trilogy on the German influence in France between the wars of 1870 and 1914. Mitchell's focus here is on the French response to the pathbreaking social legislation passed during the 1880s in imperial Germany under Otto von Bismarck. Operating under a liberal republican regime, France tended to reject the interventionist policies of its imposing neighbor and to seek a distinctly French solution to the many social problems that became more pressing as the nineteenth century reached its climax in the First World War. Mitchell's carefully researched study investigates a number of specific issues that remain of direct relevance today, such as gender relationships, health care (including the treatments and prevention of infectious disease), labor conflicts, taxation policy, social security measures, and international tensions on the eve of a major war. He shows that certain key problems of public health and welfare found different solutions in France and Germany, and he explains why the differences emerged and how they defined the two major competitors of continental Europe. The nineteenth-century epidemic of tuberculosis provides a case in point: the German state intervened to combat the dreaded disease with vigorous measures of public hygiene and popular sanatoria, but the French republic moved more cautiously to limit interference in the private sphere, even though laissez faire often meant laissez mourir. Mitchell's book is the first full-scale study of French social reform after 1870 that is based on documentation in both France and Germany. The first hesitant steps of the French welfare state are thrown into sharp relief by comparison with developments in Germany. No other work on modern France presents such a broad panorama of social reform, and none draws together such a rich tableau of telling detail about the development of the French health and welfare system after 1870. In a lucid conclusion, Mitchell places this story in the general context of his three volumes, thereby offering a summary of the Franco-German encounter that has come to dominate the history of Europe in the twentieth century. A UNC Press Enduring Edition -- UNC Press Enduring Editions use the latest in digital technology to make available again books from our distinguished backlist that were previously out of print. These editions are published unaltered from the original, and are presented in affordable paperback formats, bringing readers both historical and cultural value.

Health care under French national health insurance.

Several elements of the French health system--the predominance of office-based medical practice, the mix of private and public hospitals, the use of patient cost sharing, direct payment of physicians by patients, and financing derived from payroll taxes--closely resemble aspects of the U.S. health system. There are four major differences between the two systems: the French system covers more than 99 percent of the population; the prices of health services in French are lower than in the United States; the volume of most services is higher than in the United States; and French health care spending per capita is lower than in the United States. Recently enacted and proposed reforms in France likely will strengthen existing health spending targets and utilization controls.

Cost-effectiveness of HIV screening of pregnant women in hospitals of the Paris area

In the context of an epidemiologic multicentric study about perinatal transmission of HIV, screening was systematically proposed to all pregnant women attending nine maternities clinics of the Paris region (n = 7600, between August 1987 and July 1988) at their first prenatal visit. Among them, 2145 had already been tested and 45 were known to be HIV positive. So, 5660 tests were performed during the first 6 months (period 1), and 17 pregnant women were discovered to be positive. The total cost of screening has been estimated between FF. 720 000 and 775 000, resulting in a mean cost per pregnant woman found to be HIV positive of about FF. 42 000 to 45 000. A similar calculation over the following 5 months (period 2) gave a mean cost of between FF. 165 000 and 178 000. Since the women, before being screened, had to answer a short questionnaire about risk factors; cost and effectiveness of a selective screening strategy could be simulated. The preference of systematic screening to selective screening enabled the discovery of two HIV positive cases in each period, the marginal cost, i.e., cost per extra pregnant woman found to be HIV positive was thus FF. 303 320 to 327 540 for period 1, and FF. 572 240 to 619 000 for period 2. Although these figures seem high, an estimation of the cost-effectiveness does not allow us to conclude whether it is in society's interest to devote the funds necessary to move away from selective screening towards systematic screening. The quadrupling of the mean cost of identifying an HIV positive pregnant woman during hospital screening, despite a concomitant increase in prevalence in this population, can be explained only by an increase in prenatal screening prescribed by the private practitioner in ambulatory medicine. The evolution in the hospital program of systematic screening of pregnant women in the Paris area clearly shows that an evaluation of a policy of HIV screening amongst pregnant women depends, at least in the French health system, on the different ways in which the ambulatory and hospital sectors complement themselves when trying to cope with the monitoring of women during pregnancy.

The assessment of medical technology. The case of France.

The French health system is a complex organization that has developed since 1945 as the result of a subtle combination of two fundamental principles: liberal medicine — the freedom of both the consumers and the producers of care, and solidarity — universal access to health care — embodied in a quasi-generalized system of health insurance (4).Today, this balance, to which the French are uncontestably dedicated, appears to be precarious. It has gradually become apparent that the financing system—80% of which is based on mandatory deductions and is intended to guarantee the balance between freedom of choice and universal access — is not consistent with the dynamic of health expenditures. The growing costs of care, as witnessed by the increase of health expenses as a percentage of total household expenses from 4.5% in 1950 to 13.3 in 1985, has led to increased state control over the health care system since 1975.