The French Lesson In Health Care
The nation's system isn't quite as superb as Sicko maintains, but it's pretty good
Michael Moore's documentary Sicko trumpets France as one of the most effective providers of universal health care. His conclusions and fist-in-your-gut approach may drive some Americans up the wall. But whatever you think of Moore, the French system—a complex mix of private and public financing—offers valuable lessons for would-be health-care reformers in the U.S.
In Sicko, Moore lumps France in with the socialized systems of Britain, Canada, and Cuba. In fact, the French system is similar enough to the U.S. model that reforms based on France's experience might work in America. The French can choose their doctors and see any specialist they want. Doctors in France, many of whom are self- employed, are free to prescribe any care they deem medically necessary. "The French approach suggests it is possible to solve the problem of financing universal coverage...[without] reorganizing the entire system," says Victor G. Rodwin, professor of health policy and management at New York University.
France also demonstrates that you can deliver stellar results with this mix of public and private financing. In a recent World Health Organization health-care ranking, France came in first, while the U.S. scored 37th, slightly better than Cuba and one notch above Slovenia. France's infant death rate is 3.9 per 1,000 live births, compared with 7 in the U.S., and average life expectancy is 79.4 years, two years more than in the U.S. The country has far more hospital beds and doctors per capita than America, and far lower rates of death from diabetes and heart disease. The difference in deaths from respiratory disease, an often preventable form of mortality, is particularly striking: 31.2 per 100,000 people in France, vs. 61.5 per 100,000 in the U.S.
That's not to say the French have solved all health-care riddles. Like every other nation, France is wrestling with runaway health-care inflation. That has led to some hefty tax hikes, and France is now considering U.S.-style health-maintenance organization tactics to rein in costs. Still, some 65% of French citizens express satisfaction with their system, compared with 40% of U.S. residents. And France spends just 10.7% of its gross domestic product on health care, while the U.S. lays out 16%, more than any other nation.
To grasp how the French system works, think about Medicare for the elderly in the U.S., then expand that to encompass the entire population. French medicine is based on a widely held value that the healthy should pay for care of the sick. Everyone has access to the same basic coverage through national insurance funds, to which every employer and employee contributes. The government picks up the tab for the unemployed who cannot gain coverage through a family member.
SAFETY NET
But the french system is much more generous to its entire population than the U.S. is to its seniors. Unlike with Medicare, there are no deductibles, just modest co- payments that are dismissed for the chronically ill. Additionally, almost all French buy supplemental insurance, similar to Medigap, which reduces their out-of-pocket costs and covers extra expenses such as private hospital rooms, eyeglasses, and dental care.
In France, the sicker you get, the less you pay. Chronic diseases, such as diabetes, and critical surgeries, such as a coronary bypass, are reimbursed at 100%. Cancer patients are treated free of charge. Patients suffering from colon cancer, for instance, can receive Genentech Inc.'s (DNA ) Avastin without charge. In the U.S., a patient may pay $48,000 a year.
France particularly excels in prenatal and early childhood care. Since 1945 the country has built a widespread network of thousands of health-care facilities, called Protection Maternelle et Infantile (PMI), to ensure that every mother and child in the country receives basic preventive care. Children are evaluated by a team of private-practice pediatricians, nurses, midwives, psychologists, and social workers. When parents fail to bring their children in for regular checkups, social workers are dispatched to the family home. Mothers even receive a financial incentive for attending their pre- and post-natal visits.
A typical PMI can be found in Goutte d'Or, a poor neighborhood at the foot of Montmartre that has been home for the past 20 years to a swelling population of immigrants from Africa and Southeast Asia. On Rue Cavé, a tidy modern building is given over entirely to caring for expecting mothers, infants, and young children. The place usually is bustling with kids scrambling over toys, while mothers, often immigrants in colorful headdresses and with babies strapped to their backs, talk to their doctors as part of twice-monthly evaluations.
PMI and other such programs are starting to get attention in U.S. health-care circles. "If we really want to ensure that no child is left behind, then the PMI system is a good way to do it," says Daniel J. Pedersen, president of the Buffett Early Childhood Fund. "It's based on the practical idea that high-quality investments made at the start of a child's life will pay huge dividends to both the child and society in the future."
To make all this affordable, France reimburses its doctors at a far lower rate than U.S. physicians would accept. However, French doctors don't have to pay back their crushing student loans because medical school is paid for by the state, and malpractice insurance premiums are a tiny fraction of the $55,000 a year and up that many U.S. doctors pay. That $55,000 equals the average yearly net income for French doctors, a third of what their American counterparts earn. Then again, the French government pays two-thirds of the social security tax for most French physicians—a tax that's typically 40% of income.
Specialists who have spent at least four years practicing in a hospital are free to charge what they want, and some charge upwards of $675 for a single consultation. But American-style compensation is rare. "There is an unspoken and undefined limit to what you can charge," says Dr. Paul Benfredj, a gastroenterologist in Paris.
Many French doctors, in fact, earn more by increasing their patient load, or by prescribing more diagnostic tests and procedures—a technique, also popular in the U.S., that inflates health-care costs. So far France has been able to hold down the burden on patients through a combination of price controls and increased government spending, but the latter effort has led to higher taxes for both employers and workers. In 1990, 7% of health-care expenditures were financed out of general revenue taxes, and the rest came from mandatory payroll taxes. By 2003, the general revenue figure had grown to 40%, and it's still not enough. The French national insurance system has been running constant deficits since 1985 and has ballooned to $13.5 billion.
That's why France is gearing up to make changes. It already requires patients to register with a general practitioner before visiting a specialist, or else agree to a lesser reimbursement, much like many U.S. insurance plans. But France isn't likely to make major changes to a system most citizens say they like. Why would they? Says Shanny Peer, policy director at the independent French-American Foundation: "France gets better results for less money and everyone is covered."
Showing posts with label Health Care issues. Show all posts
Showing posts with label Health Care issues. Show all posts
Wednesday, February 4, 2009
Thursday, January 29, 2009
With our economy in crisis, President Barack Obama newly sworn in and health reform hearings under way this week in the Legislature, only one thing is certain about U.S. health care: We cannot afford the status quo.
The silver lining in this crisis is that it offers us the opportunity to build a high-quality, sustainable health system -- one founded on the premise that every person should be able to get the health care they need, rather than viewing health care as a consumer product that we can buy or forgo.
Patients get sicker, and cost more, when care is delayed. Take, for example, Joey, an uninsured 3-year-old whose mother couldn't afford asthma medications. As a result, Joey wound up in the emergency room with a serious asthma flare costing 10 to 15 times more than the medicine that would have prevented it. Or David, a retired store manager who, despite his Medicare coverage, was unable to find a doctor to treat complications of stepping on a thumbtack with a foot rendered numb from years of diabetes, because he lacked a Medicare supplemental policy. After searching for weeks in vain, he finally came to the hospital, his foot now afflicted with gangrene and in need of an emergency amputation. Timely care would have saved his foot at a tiny fraction of the cost.
As a society, we pay dearly, in human terms and in cold dollars, when people lack access to care. Now, with such giants as Microsoft, Starbucks, Boeing and Washington Mutual announcing job layoffs, more people will lose their health benefits. And, like Joey and David, when they get sick or injured, many will get care only when their situation becomes an emergency. Those high expenses are passed on to all of us in the form of skyrocketing health costs.
In an effort to develop options, the Legislature commissioned an economic analysis of five state health reform proposals. The analysis, prepared by Mathematica Policy Research, will be presented at hearings this week. In these tumultuous times, it may be tempting for lawmakers to favor the plan that costs the least in the short run, or to take no action. But that won't make people's unmet health needs go away.
As physicians, we believe the only way to create a durable system -- one that is equitable and affordable, allowing everyone to get the care they need -- is to design it around human rights principles that make protection of health paramount.
Using that approach, Northwest Health Law Advocates has just released a human rights evaluation of the five proposals that complements Mathematica's primarily economic analysis (available at nohla.org). NoHLA found that some reform proposals -- those that would cover all state residents -- are better than others but all need to pay more attention to human rights values.
And that is what Washingtonians want. In eight health care caucuses around the state in 2008, more than 1,000 people emphasized the need for universal coverage, affordability and access for all, reflecting those values.
Fortunately, the ethical choice is also the economically prudent choice. There is a false perception that we must choose between lower cost and broader access.
But creating a health system for all is the only sustainable solution over the long haul. It is the only way to prevent the sad stories and poor health outcomes physicians see every day. The quick fixes will just widen disparities and reduce access, which will drive up costs in the long run. Investing in comprehensive coverage, so the Joeys and Davids of our country get timely, appropriate care rather than requiring expensive treatment, will save money and improve health.
The best measure of who we are as a people is how we behave in times of crisis. As state and federal lawmakers consider options for reform, they should treat health care not as just another consumer product, but as a basic human right, like clean air and water.
Benjamin Danielson, M.D., is medical director of the Odessa Brown Children's Clinic and teaches at the University of Washington. Hugh Foy, M.D., is a Seattle physician, surgeon and educator.
The silver lining in this crisis is that it offers us the opportunity to build a high-quality, sustainable health system -- one founded on the premise that every person should be able to get the health care they need, rather than viewing health care as a consumer product that we can buy or forgo.
Patients get sicker, and cost more, when care is delayed. Take, for example, Joey, an uninsured 3-year-old whose mother couldn't afford asthma medications. As a result, Joey wound up in the emergency room with a serious asthma flare costing 10 to 15 times more than the medicine that would have prevented it. Or David, a retired store manager who, despite his Medicare coverage, was unable to find a doctor to treat complications of stepping on a thumbtack with a foot rendered numb from years of diabetes, because he lacked a Medicare supplemental policy. After searching for weeks in vain, he finally came to the hospital, his foot now afflicted with gangrene and in need of an emergency amputation. Timely care would have saved his foot at a tiny fraction of the cost.
As a society, we pay dearly, in human terms and in cold dollars, when people lack access to care. Now, with such giants as Microsoft, Starbucks, Boeing and Washington Mutual announcing job layoffs, more people will lose their health benefits. And, like Joey and David, when they get sick or injured, many will get care only when their situation becomes an emergency. Those high expenses are passed on to all of us in the form of skyrocketing health costs.
In an effort to develop options, the Legislature commissioned an economic analysis of five state health reform proposals. The analysis, prepared by Mathematica Policy Research, will be presented at hearings this week. In these tumultuous times, it may be tempting for lawmakers to favor the plan that costs the least in the short run, or to take no action. But that won't make people's unmet health needs go away.
As physicians, we believe the only way to create a durable system -- one that is equitable and affordable, allowing everyone to get the care they need -- is to design it around human rights principles that make protection of health paramount.
Using that approach, Northwest Health Law Advocates has just released a human rights evaluation of the five proposals that complements Mathematica's primarily economic analysis (available at nohla.org). NoHLA found that some reform proposals -- those that would cover all state residents -- are better than others but all need to pay more attention to human rights values.
And that is what Washingtonians want. In eight health care caucuses around the state in 2008, more than 1,000 people emphasized the need for universal coverage, affordability and access for all, reflecting those values.
Fortunately, the ethical choice is also the economically prudent choice. There is a false perception that we must choose between lower cost and broader access.
But creating a health system for all is the only sustainable solution over the long haul. It is the only way to prevent the sad stories and poor health outcomes physicians see every day. The quick fixes will just widen disparities and reduce access, which will drive up costs in the long run. Investing in comprehensive coverage, so the Joeys and Davids of our country get timely, appropriate care rather than requiring expensive treatment, will save money and improve health.
The best measure of who we are as a people is how we behave in times of crisis. As state and federal lawmakers consider options for reform, they should treat health care not as just another consumer product, but as a basic human right, like clean air and water.
Benjamin Danielson, M.D., is medical director of the Odessa Brown Children's Clinic and teaches at the University of Washington. Hugh Foy, M.D., is a Seattle physician, surgeon and educator.
Wednesday, January 28, 2009
Mr president a word please
Dear Obama: A Letter About Health-Care Reform
Working to change the system that's already there is not enough. We need a complete overhaul of our health-care model
By Dr. Ralph de la Torre
Dear President Obama,
As a concerned medical professional, I am gratified that health-care reform will have such a high priority in your new Administration. It was especially pleasing to see that one of your very first Cabinet selections was Secretary of Health & Human Services.
You have spoken often about the flaws in the U.S. health-care system and the grave risks, in both human and fiscal terms, associated with not correcting them. As a current hospital CEO and former heart surgeon, I'd like to share my perspective on today's health-care problems and recommend a course of action.
According to your Web site, "the Obama-Biden plan&builds on the existing health-care system." With all due respect, I believe that simply adjusting our current model would be a mistake similar to the one the Clintons made when they tried unsuccessfully to reform health care early during that Administration. We can't simply tweak elements of the system while leaving the rest intact. It's time to overhaul the entire model.
To start fresh, we need to clarify the three basic concepts of every health-care discussion: access, cost, and quality. We need to answer the following questions:
• How should we define access? Should every U.S. citizen have a primary care physician? Should anyone on U.S. soil at any given moment be entitled to medical care? Should the elderly and the very poor continue to have access that others do not? Does "access" define all medical care without reservation?
• How much should health care cost in the U.S.? Is 20% of gross national product acceptable (the level we expect to reach by 2016, if the present system remains unchanged), or should we aim for less? How much of that cost should be borne by employers, and how much by the government? What should an American family reasonably pay for health care?
• Where should we set the parameters for quality? Do we want to shoulder the tremendous costs of medicine that meet the very highest standards? What should be the goals for infant mortality, cancer survival rates, and other such metrics?
Defining access, cost, and quality will set the baseline requirements the new system must satisfy. These conditions, rather than any vague goal such as "universal care" or "affordability," should be the starting points for reform. Without them, any plan will soon hit financial and demographic obstacles that will derail it completely.
Arriving at consensus on such basic yet critical questions will not be an easy feat. That's why I suggest you launch a kind of 90-day Manhattan Project as soon as possible. Invite 50 to 70 of our country's smartest thinkers—people willing to spend three months in Washington—to solve what is one of the biggest domestic problems facing the U.S. today. Avoid policy wonks and business consultants, simply because the economics of health care differ so radically from those of other industries. Station the National Guard at every entrance to the meeting room and instruct them to keep out all lobbyists.
Who should be on this "A-Team?" Obviously, you'll need to select representatives from the relevant groups: physicians and hospital administrators, insurers and drugmakers, as well as legislators and their constituents. But two-thirds of the conferees should be crossovers, such as doctors who left their practices to run hospitals or administrators who switched to insurance. That way, they'll speak each other's languages and be equipped to talk from both sides of the table. Fortunately, many highly regarded individuals fit those descriptions, including former Senate Majority Leader Bill Frist, who has gone back to practicing medicine.
The IT Factor
In addition to building consensus around the baseline questions, it is vital that we understand that information technology may ultimately be the most important element of health-care reform. While I applaud your five-year, $10 billion IT spending plan, I'm afraid it will barely scratch the surface of the nation's need for medical data sharing. My six-hospital chain alone is budgeting $73 million over the next three years to upgrade its medical-care technology.
People talk about the potential cost-savings of integrating medical IT so that hospital computers can communicate with one another, as well as with primary-care offices and with imaging labs across the country. But the real payoff from IT investment will be the birth of truly preventive medicine. Imagine an integrated system that lets us identify populations at high risk for conditions such as hypertension or diabetes and thus encourages intervention before patients get sick, instead of just before they need high-risk, expensive procedures like cardiac surgery or foot amputation. Effective data sharing will give researchers the tools to reach that level of analysis. We should no longer define prevention as lifetime treatment of chronic disease.
Predictably, the companies now competing in the medical data field will balk at cooperating to such a degree. And, finding answers to the basic baseline questions will no doubt result in strenuous argument. But, those are hurdles project members can clear. While the plan they produce won't please everyone (truthfully, it should completely please no one), the ultimate objective must be an agreement that transcends all vested interests. I firmly believe that, just as the greatest American minds could put people on the moon and invent the atomic bomb, they can also create a world-class, sustainable health-care system.
When the panel emerges with a plan, it must be followed immediately by a transition time line—perhaps six to seven years—during which an initial pilot program would expand in an orderly fashion, piece by piece. But it's imperative that this process begin right away. If we don't tackle health-care reform within weeks of Inauguration Day, the will for change that has built up so powerfully during your campaign will quickly evaporate. This is an opportunity our nation can ill afford to squander.
Working to change the system that's already there is not enough. We need a complete overhaul of our health-care model
By Dr. Ralph de la Torre
Dear President Obama,
As a concerned medical professional, I am gratified that health-care reform will have such a high priority in your new Administration. It was especially pleasing to see that one of your very first Cabinet selections was Secretary of Health & Human Services.
You have spoken often about the flaws in the U.S. health-care system and the grave risks, in both human and fiscal terms, associated with not correcting them. As a current hospital CEO and former heart surgeon, I'd like to share my perspective on today's health-care problems and recommend a course of action.
According to your Web site, "the Obama-Biden plan&builds on the existing health-care system." With all due respect, I believe that simply adjusting our current model would be a mistake similar to the one the Clintons made when they tried unsuccessfully to reform health care early during that Administration. We can't simply tweak elements of the system while leaving the rest intact. It's time to overhaul the entire model.
To start fresh, we need to clarify the three basic concepts of every health-care discussion: access, cost, and quality. We need to answer the following questions:
• How should we define access? Should every U.S. citizen have a primary care physician? Should anyone on U.S. soil at any given moment be entitled to medical care? Should the elderly and the very poor continue to have access that others do not? Does "access" define all medical care without reservation?
• How much should health care cost in the U.S.? Is 20% of gross national product acceptable (the level we expect to reach by 2016, if the present system remains unchanged), or should we aim for less? How much of that cost should be borne by employers, and how much by the government? What should an American family reasonably pay for health care?
• Where should we set the parameters for quality? Do we want to shoulder the tremendous costs of medicine that meet the very highest standards? What should be the goals for infant mortality, cancer survival rates, and other such metrics?
Defining access, cost, and quality will set the baseline requirements the new system must satisfy. These conditions, rather than any vague goal such as "universal care" or "affordability," should be the starting points for reform. Without them, any plan will soon hit financial and demographic obstacles that will derail it completely.
Arriving at consensus on such basic yet critical questions will not be an easy feat. That's why I suggest you launch a kind of 90-day Manhattan Project as soon as possible. Invite 50 to 70 of our country's smartest thinkers—people willing to spend three months in Washington—to solve what is one of the biggest domestic problems facing the U.S. today. Avoid policy wonks and business consultants, simply because the economics of health care differ so radically from those of other industries. Station the National Guard at every entrance to the meeting room and instruct them to keep out all lobbyists.
Who should be on this "A-Team?" Obviously, you'll need to select representatives from the relevant groups: physicians and hospital administrators, insurers and drugmakers, as well as legislators and their constituents. But two-thirds of the conferees should be crossovers, such as doctors who left their practices to run hospitals or administrators who switched to insurance. That way, they'll speak each other's languages and be equipped to talk from both sides of the table. Fortunately, many highly regarded individuals fit those descriptions, including former Senate Majority Leader Bill Frist, who has gone back to practicing medicine.
The IT Factor
In addition to building consensus around the baseline questions, it is vital that we understand that information technology may ultimately be the most important element of health-care reform. While I applaud your five-year, $10 billion IT spending plan, I'm afraid it will barely scratch the surface of the nation's need for medical data sharing. My six-hospital chain alone is budgeting $73 million over the next three years to upgrade its medical-care technology.
People talk about the potential cost-savings of integrating medical IT so that hospital computers can communicate with one another, as well as with primary-care offices and with imaging labs across the country. But the real payoff from IT investment will be the birth of truly preventive medicine. Imagine an integrated system that lets us identify populations at high risk for conditions such as hypertension or diabetes and thus encourages intervention before patients get sick, instead of just before they need high-risk, expensive procedures like cardiac surgery or foot amputation. Effective data sharing will give researchers the tools to reach that level of analysis. We should no longer define prevention as lifetime treatment of chronic disease.
Predictably, the companies now competing in the medical data field will balk at cooperating to such a degree. And, finding answers to the basic baseline questions will no doubt result in strenuous argument. But, those are hurdles project members can clear. While the plan they produce won't please everyone (truthfully, it should completely please no one), the ultimate objective must be an agreement that transcends all vested interests. I firmly believe that, just as the greatest American minds could put people on the moon and invent the atomic bomb, they can also create a world-class, sustainable health-care system.
When the panel emerges with a plan, it must be followed immediately by a transition time line—perhaps six to seven years—during which an initial pilot program would expand in an orderly fashion, piece by piece. But it's imperative that this process begin right away. If we don't tackle health-care reform within weeks of Inauguration Day, the will for change that has built up so powerfully during your campaign will quickly evaporate. This is an opportunity our nation can ill afford to squander.
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