La Vie Francaise

Posted 08/30/2011

With the World Health Organization ranking the United States 37^th in “quality of healthcare to its citizenry,” a notch below Costa Rica but thankfully edging out Slovenia, perhaps it crossed your mind, as it did mine, how health care is delivered in the top-ranked country,  France.

As a physician heading into his fourth decade of practice, I feel qualified to list how the US managed to end up at number 37, but rather than bash our system (again), this week we’re going to discuss how the French manage to stay on top in surveys like these.

At the heart of the matter lies the French attitude toward health care. As deeply entrenched in the American psyche as our love of guns, our “right to bear arms,” is the French belief that every single citizen has an unquestionable right to affordable health care. A system like ours–one that gives preference to the rich, the powerful, and the employed while leaving upward of 50 million citizens with no health care–is simply abhorrent to them. The French read about the US system and find the degree of injustice simply incomprehensible (to be honest, so do many Americans).

The system France has created would stick in the craw of any card-holding Libertarian because the government is very much involved (as the government is here in the US, though in a different way). And while the rules of their system are tinkered with incessantly, the French are generally very proud of it.

A mandate to buy, but from a non-profit insurer

To begin, by law every citizen must buy health insurance, with no provision for opting out. There are numerous health insurance companies, all of them non-profit and regulated by the government to function solely as conduits for premiums collected and benefits paid to health care providers and enrollees (patients).

There are no investors in French health insurance companies, no stocks traded on the market. You would no more invest in a French health insurance company than you would in the Red Cross. There are definitely no CEOs collecting multimillion dollar salaries. At these health insurance companies, no full-time staff spends their days “withholding payments to providers” or denying benefits for so-called pre-existing conditions.

In France, the incessant bickering between insurer, enrollee (that’s you), and provider (that’s me) is non-existent, resulting in a steep reduction of administrative staff. And the financial savings are impressive: in the US, health insurance companies keep 20% of premium dollars for administration, in France, it’s 5%.

The French have different health insurance companies for different needs. Most people are employed and, like many employed Americans, purchase insurance through their employer. Rates are quite low, mainly because health care costs are low. A person earning $40,000 a year pays roughly $22 a month for her insurance, while her employer contributes $200 a month.

Self-employed individuals purchase their insurance through a separate company, rate determined by income. Unemployed people have their entire premium paid by the government. If you lose your job, you simply switch to the government plan until you find another job.

In France…

• You can never lose your insurance.
• It is not possible to be uninsured.
• You can never be denied benefits for any reason.
• The concept of a “pre-existing condition” is unknown.
• You can always see any doctor you like, primary or specialist.
• There are no networks to contend with.
• Doctors are not gatekeepers (in the US, primary care physicians are used by many managed care plans as gatekeepers who control costs).
• The waiting time to see a physician or undergo a surgical procedure is the same as in the US.

Costs are regulated

Costs are lower because the fee for every possible service–from a doctor’s office visit or injection to a lab test, surgical procedure, prescription drug, or hospital stay–is tightly regulated by the government. Certain elective procedures, such as cosmetic surgery, aren’t covered, but for this you can purchase a supplemental policy similar to our Medicare supplement insurance.

Surprising to visitors, every physician’s office has the government fee schedule for his or her specialty posted prominently at check-in. All French fees are shockingly lower than those in the US. A typical office visit to a primary care doctor costs about $30. Keep in mind, however, that in France medical school is completely free, malpractice insurance rates are a tiny fraction (1 to 2%) of what doctors pay in the US, and French doctors don’t need any extra staff to collect fees from or argue with insurance companies. Professional payments are automatique.

The medical offices themselves, whether housing family physicians or specialists, are surprisingly simple–almost austere by US standards–small in size and minimally staffed yet perfectly suited to a doctor’s needs. Pretentious office décor is a non-issue for French patients and physicians alike.

These limits on cost produce some remarkable numbers

• The French visit their doctors more times per year than Americans (8 visits versus 5) and also swallow more pills. Yet the French system spends less than half what’s spent in the US.
• France spends $3,200 per person per year for a system that covers everybody.
• The US spends $7,500 per person for a system that positions us 37^th and leaves 50 million people without access to health care.
• Overall, France spends less than 10% of its total national wealth (measured as Gross National Product, or GNP) on health care.
• In the US, we spend more than 17% of ours.

The carte vitale

A central component of the French system is the carte vitale, the plastic “vital card” containing a computer chip that holds your entire health history–all test results, hospitalizations, and a record of all doctor visits. When you go to any physician, you hand over your carte vitale and it’s placed into a card reader so the doctor can review your complete medical history. After providing treatment, the doctor enters updated notes onto your carte, including the price of your visit, and presses the send button. Immediately you learn your co-pay for that visit (maximum of $100) and within three days, both you and your doctor receive benefit checks from your insurance companies.

There are no deductibles, but on principle there is always a co-pay unless your income is at poverty level, in which case your visit is completely free. Whether you’re at poverty level or the CEO of a major company, your physician is paid the same amount of money for his or her services. There is no squabbling with your insurer about whether your Pap smear is covered. There is no stigma to being poor or unemployed.

The same carte vitale system pays your hospital, pharmacist, and physical therapist. And clearly, having a detailed health history in your pocket saves a fortune on unnecessary duplication of tests.

The carte vitale completely eliminates paper. In my basement at home, I store roughly 100 cases filled with the inactive charts of patients who have moved away or changed insurance companies and as a result were forced into a different physician network.  I must by law store these charts for years before they’re shredded. Just the thought of getting my basement back makes me fond of the French system.

And the system does seem to work well

In a key measurement called Mortality Amenable to Health Care, which simply means “ability to cure people who have curable conditions,” the French rank near the top–well above the US.

Our infant mortality rate is much higher than France’s, and the French have a higher life expectancy than Americans. A healthy 60-year-old French woman can expect to live to 81. An American woman of the same age averages 77.

Surveys show that French physicians are happy with all this, despite complaining about their reimbursement. Unlike their US counterparts, French physicians are tightly unionized and when demanding a rate increase they simply go on strike.

Across the board, US physicians earn twice, if not more, the salary of French physicians. Keep in mind that being a physician in France means being “comfortable,” but certainly not rich. The idea of the wealthy doctor, the gastroenterologist who makes a half million a year, the neurosurgeon bringing in a cool million, is uniquely American.

In France, you get into medical school on your brains alone and the government picks up the tab. In the US, you generally need to be from an upper middle class family, and you leave med school straddled with $140,000 in debt. Add the huge dollars needed for malpractice insurance–plus the high costs of running an office filled with employees who spend the day arguing with insurance companies–and you can easily grasp why an  American physician’s practice is money-oriented.

In surveys, French physicians report their lives as “satisfying.” On the other hand, and for all the reasons you’d surmise–insurance bickering, endless paperwork, malpractice threats, and millions of uninsured Americans (remember, the AMA supported Obamacare)–comparable surveys of US physicians show that 75% discourage their children from a career in medicine.

Sadly, the one word that rarely surfaces in these US surveys is “satisfying.”

As always, for your own sake, stay well,

David Edelberg, MD