Marianne Samuelson

1
Is it possible to improve  navigation  of
patients in the French health care
system? Experience of organised networks  Les
réseaux 
Marianne Samuelson Utrecht october 2006
2
French Health care systemMain features

• Fee for service payment
• GPs have no real gate keeping function and there
  is no regulation of the circulation of patients
  within the system
• Unequal distribution of doctors throughout the
  country
• Most specialists are in private practices in
  ambulatory care
• Isolated health care professionals in private
  practices (nurses, and so) very little contact
  with social workers
• A very complex health insurance system
• 1996 a short attempt to introduce patients lists
  and capitation on a voluntary base (médecin
  référent)
• 2005 Health care reform introducing mandatory
  patient list without capitation (médecin
  traitant)

3
System organised for acute episodes of care

• System centred on acute episodes
• Patient role not emphasised
• Follow up sporadic and not organised
•  Prevention is neglected
• Holistic approach is not a priority

4
Why was France ranked first by WHO in 2000

• Availability of supply of providers
• High degree of freedom for physicians and
  patients
• Few restriction in the range of services covered
  by the health insurance system
• Easy access
• Absence of waiting list
• Patient satisfaction

5
European challenges / French context

• Aging population
• Chronic diseases
• Cultural and ethnical diversity
• Scientific progress
• Patient involvement
• Tasks division among health care providers

6
Two questions

• Is it still possible to maintain the ideal
  synthesis of solidarity, liberalism, and
  pluralism ? Claude Le pen
• N Engl J Med November 2004
• Is French health care system adapted to face the
  future European challenges

7
Navigation through the health care system.
8
A need for change..

• Social changes
• Medical demography
• Workload acceptance
• Consumers/citizens demands for transparency/qualit
  y
• Healthcare system with no culture of change
• Top down organisation with big hierarchy between
  hospitals, ambulatory specialists, GPs and other
  health care providers as nurses
• Medical and technical knowledge emphasized rather
  than approach to health
• Recent introduction of OI methods
• Big differences in medical demography in the
  country
• Lack of communication among health care providers
• Financial problems
• System not cost effective
• Introduction of co payment
• A lot of basic services not refunded by the
  Insurance system (ex pedicure, psychologist, )

9
A political will

• The government tries to explore and experiment
  instead of imposing a real reform. Policy makers
  bet on collective learning rather than regulating
  by promoting creation of networks
• These networks are not a really institutionalized
  new offer of care, but an attempt to reform the
  system at a slow pace
• Legislation and financing
• The first networks were initiatives of doctors to
  respond to unsolved problems or poor quality
• 1991 to 1995 creation of the first networks of
  health care providers for HIV patients, drug
  addicts and hepatitis.
• 1996 a law reforming public and private hospitals
  and promoting networks between hospitals and
  ambulatory practice (including GP and
  specialists)

10
Definition of Networks RéseauxIn the law of
2002

• Health care networks are aimed to improve access,
  coordination, continuity and multidisciplinary
  work for specific populations, health conditions,
  or health care tasks. They should be able to
  offer adapted care to the patients including
  health promotion, prevention, diagnostic and care
  procedure. They can contribute to public health
  campaigns. They should assess there activity too
  guaranty quality of their intervention.They may
  include ambulatory care providers, occupational
  doctors, hospitals, health care centres and
  social institutions with participation patients
  representatives.

11
Financial aspects

• Finances of these network is include since 2002
  in the national health financing plan voted by
  the parliament every year.
• The special budget for the networks doubled every
  year since 2002.
• Financing of networks are adapted to national and
  regional priorities
• Special services not included in normal range of
  refunded medical services can be funded with
  their budget (examplelay care services,
  pedicure, psychologist, dietetician ..
• The networks receive finances for three years
  maximum with possibility to reapply after
  assessment procedures
• Connections with other financing possibilities
  (CME, QI, hospital projects..other specific
  budgets)

12
Principles and objectives

• Respond to specific health problems (HIV,
  addictions, diabetes, hepatitis) or a defined
  population groups (special geographic area, or
  dependant people.)
• Holistic approach (prevention/curative,
  clinical/social)
• Written procedures and protocols following
  guidelines
• Patients and doctors join on a voluntary base.
• Medical and administrative coordination
• QI methods implemented
• Secured information systems
• Assessments procedures

13
A great diversity of type network

• Some of them are community centred (palliative
  care, aging people, mother and child care.) /
  Some are disease centred (cancer, diabetes,
  hepatitis..)
• Some of them are top down organised from the
  hospital( rare diseases, cardiology ) / Some are
  chaired by GPs
• Some of them are medico socially focussed / Some
  are focused on specific techniques (cardiology..)

14
Strengths

• Feeling for a need of change and a political will
• Experimenting rather than imposing
• Regional health policy rather than centralised
• Motivated actors
• Access for patients to services that are
  otherwise not financed by the Health Insurance
  system
• Various finances possibilities
• Holistic approach to health problems
• Medical and administrative coordination
• Collective learning
• Tackling organisational aspects of care
• QI methods implemented
• Secure information system
• Expected change in the system and introduction of
  a culture of change

15
Weaknesses

• Only on experimental basis
• Only few local policy makers involved
• Very little commitment of health care
  professional in collective actions
• Inequity due to the unequal geographical
  distribution
• Introduction of financial inequities, whether
  patients with the same condition are involved in
  a network or not
• Very complicated process to create these networks
  (big work to build up the files, to promote it,
  to involve health care providers)
• Long tradition in France of individual and
  isolated working habits to overcome
• A fragile process in his dynamic
• A huge variation in communicating information
  systems
• Administrators not well accepted by doctors
• QI procedures and assessment perceived as
  control
• Often unclear organisation of work perceived from
  outside
• Overlap in services
• No global overview of the system

16
Opportunities

• Collective learning
• Long lasting financial resources for variety of
  services
• Conception of health care going beyond pure
  clinical care
• New type of relation among health care
  professionals
• Improvement of communication
• Better understanding of differences in
  professionals cultures
• Organisational aspects and cooperation procedures
  used in this environment could be transferred to
  other health problems
• Better understanding of community problems

17
Threats

• Only experimentation is funded at the starting
  point
• Permanent funding submitted to assessment
• At the moment no idea of the effects and outcomes
• Lacks of professionals willing to innovate
• Opportunistic projects
• Lack of understanding of health care policy among
  providers
• Dominant top down hospital/ambulatory care model
• Medical education not population focused
• Hierarchy among health care professionals
• Health care professionals reluctant to join
• Health care professionals afraid of change
• QI methods and protocols perceived as control
• To many Networks in the same area and no real
  cooperation
• Conservative medical profession

18
Conclusion

• Questions
• Are these networks the adapted answer to the
  problems that we face in our health care system?
• Does this type of organisation improve
  navigation of patient in the system?
• Do they improve communication among professionals
  and introduce the culture of change we need?
• No clear answer until now
• Some reflection
• An official report analysing all these
  experiences has been written but not publicly
  issued , it seems to show a big doubt on cost
  effectiveness
• A very stimulating an innovative attempt to
  reorganise the offer of care but no strong enough
  political will to transform experiences in a real
  structuring reform