By John Carruthers, contributing writer, August 01, 2014
Each month, Dermatology World tackles issues “in practice” for dermatologists. This month’s column looks at how dermatology is practiced in France and how that country’s health system handles paying for medical training and treatment.
The health system in France, regularly ranked among the best in the world by the World Health Organization (WHO), provides some significant contrasts to the care delivery system of the U.S. The French system is notable for being largely funded by the government — 77 percent of all health spending is covered by government funding through a variety of national agencies, according to the WHO. (See sidebar for a breakdown of U.S. health spending.) France as a whole spends 6 percentage points less of its gross domestic product on health care than the U.S. — 11.6 percent of GDP, compared to the U.S.’s 17.9 percent, according to the CIA World Factbook. While both countries are known for world-class medicine and share similarities, the French government funds a much wider swath of the system directly, from medical training to pre- and post-natal care, as well as completely subsidized care for those with chronic diseases, including cancer.
Free care, free medical training
Health care in France is provided to all residents who remain in the country at least three months — regardless of whether they pay into the social security system — through a social insurance model. Coverage also extends to French overseas departments, such as Guadeloupe, Mayotte, and Martinique. Everyone is covered for catastrophic and costly treatment and procedures through the government’s Assurance Maladie, with most citizens also extending their coverage through private insurance known as a mutuelle, offered through the private market. Employers will often cover an employee’s mutuelle coverage, but plans are also offered and advertised to citizens to purchase individually. These plans reimburse for fees that the national plan does not, such as the 20 percent of hospital fees not covered under Assurance Maladie, or the specialist consultation fee that a physician may charge over a government-set reimbursement amount.
The government, which accounts for the vast majority of health spending, uses its purchasing power to negotiate better prices for procedures and prescriptions. Physician and dental consultations, as well as common procedures, are reimbursed by the public system at 70 percent of a fixed cost set by the government, and depending on coverage, the remainder can be paid by a patient’s mutuelle. The charge to a patient for a general consultation is €6.90 ($9.60), while a specialist consultation is €7.50 ($10.85). This is true for both new patient consultations and follow-ups. Providers are reimbursed for consultations at the same level regardless of the reason for the visit — €23 for a general consult and €25 for a specialist consult.
French citizens who register and pay into the system, or who are members of household that has an income below a set poverty amount — which, together, amount to nearly everyone in the country — are given a card known as a Carte Vitale that enables them to receive treatment and medication at reduced cost; those without a Carte Vitale wait longer for reimbursement after they seek treatment. The Carte Vitale, which is presented to a receptionist, pharmacist, or directly to a doctor prior to treatment, contains all of the patient’s coverage information, and allows patients to receive expedited reimbursement after paying their consultation and/or prescription fee up front. (Costs are initially borne by patients; they are reimbursed through both the public system and any applicable mutuelle coverage following a visit or receipt of prescription medication. For patients who are unable to pay a copay and wait for reimbursement, hospital clinics often provide free treatment, though wait times are often significant.) [pagebreak]
Prescription medicine is reimbursed at a variable rate beginning at 35 percent of cost and extending to 100 percent for medications that would be difficult or impossible for patients to afford on their own. This, according to Paris dermatologist Daniel Wallach, MD, makes treating patients with chronic or severe conditions somewhat easier. There are four levels of reimbursement that range from 15 – 100 percent reimbursable. Unless there is no generic equivalent, branded drugs are not reimbursed — patients can request a specific brand, but will only be reimbursed at a rate equal to the generic.
“In France, when you have a very expensive drug, like a biologic, patients don’t pay anything for it,” he said. “If it’s on the market, the health insurance pays for it. It’s one of the main differences in the French system.”
France is the second-largest pharmaceutical market in the European Union, and the number of approved biologic drugs is comparable to the U.S., according to dermatologist Olivier Chosidow, MD, PhD, of Creteil, a suburb of Paris, who is president of the Societe Francaise de Dermatologie. In a controversial move, the government recently announced plans to allow pharmacists to substitute biosimilars as part of the 2014 health care budget. The total savings to the system is projected at between €500,000,000 and €1,000,000,000 by 2020, when a host of existing patents on biologic drugs expire and biosimilar versions will likely drive further cost savings.
The system is funded through fees taken from workers and their employers, known as contributions sociales, that are separate and distinct from the taxes that pay for police, infrastructure, and so forth, according to Dr. Wallach. The fees fund the health system much in the way that payroll taxes in the U.S. fund Medicare and Social Security.
Medical school in France is available to students directly after the completion of secondary school, and all students are able to attend the first year of medical school regardless of their degree or prior grades. This year includes mostly general medicine-related scientific training that closely resembles the course requirements for aspiring medical students in their junior and senior years of college in the U.S.
According to Dr. Chosidow, the first year is extremely competitive, culminating in a system-wide exam that sees only 10 percent of students qualify to continue studying medicine. The exam — similar to the MCAT in the U.S. — keeps the threshold of medical students in the second year and beyond at a level below the maximum number allowed by government regulation.
Following the exam, students complete another year of scientific training before moving on to a four-year cycle beginning with a year of general medical training and continuing to three years of pathology and therapeutics training. The medical schools are part of the public education system and are, therefore, free.
Afterward, medical school graduates take another examination for residency and split their time between their chosen specialty and a different complementary one.
“Residents are requested to train in non-dermatology practice in internal medicine, infectious disease, rheumatology, or another specialty,” Dr. Chosidow said. “You become a dermatologist after 10 to 11 years of training, provided you have spent at least half of your time in residency practicing dermatology.” [pagebreak]
Dermatology and the workforce
There are 3,400 practicing dermatologists in France, according to dermatologist Brigitte Roy-Geffroy, MD, executive director of the Societe Francaise de Dermatologie. The ratio of dermatologists to French citizens is around one for every 19,488 people, compared to the U.S. rate of one per 39,286. Despite the more favorable specialist ratio, however, French patients face waits and maldistribution issues similar to dermatology patients in the U.S. According to Dr. Wallach, private-practice dermatologists in France see between 110 and 150 patients per week.
“For patients, the wait for a dermatologist appointment is typically several weeks. Many times, they either see a general practitioner, visit a primary care doctor in a hospital clinic, or don’t see anyone,” Dr. Wallach said. “Most of the dermatologists are in urban areas — there are far more dermatologists in Paris than in the countryside. The larger academic centers and patient populations make it a more attractive place to practice.”
In contrast to the U.S. a far greater proportion of the dermatology workforce practices in a hospital setting, whether as an academic dermatologist, employed hospital physician, or private practitioner, according to Dr. Chosidow.
“In a university-based hospital, you may have academic positions and non-academic positions. You also have office-based dermatologists who come to a hospital once or twice a week for hospital-based practice,” he said. “They may have a psoriasis clinic, a general dermatology clinic, a sexually transmitted diseases clinic, or even a surgery clinic.”
In addition, diseases with dermatologic symptoms, such as AIDS, metastatic melanoma, and toxic epidermal necrolysis, are treated in concert with other related specialists, such as oncologists and infectious disease specialists, in dermatologic inpatient departments. In his practice at the Hopital Henri Mondor department of dermatology, Dr. Chosidow said, there are two dedicated hospital beds for rare and serious conditions. This provides contrast to the U.S., where patients are usually admitted by other physicians or specialists with dermatologists consulting.
“On a daily basis, I’m facing severe patients, with toxic epidermal necrolysis, necrotizing fasciitis, severe internal medicine-related skin conditions,” Dr. Chosidow said. “We have dermatologic emergencies here 24 hours, seven days a week, which is unique in the dermatology world.”
Patients who wish to see a dermatologist are encouraged to first visit a general practitioner and receive a referral to a dermatologist. It’s known as the parcours de soins, the path to care. Most patients, Dr. Wallach said, choose instead to make appointments directly, which means they will be reimbursed at a 40 percent lower rate, and will need to pay a tax of €4-5 into the system, as well as any other fees that dermatologists may set individually — dermatologists are allowed to set additional fees for any appointment, though most do so for directly scheduled appointments, he said.
“In theory, patients should visit a general practitioner first to receive the maximum amount of reimbursement,” Dr. Wallach said. “In practice, the majority of patients go directly to dermatologists because they’re used to it, it’s less expensive if they’re not also visiting a general practitioner first, and the dermatologist is used to direct appointments.”
Dr. Chosidow said that in general, patients tend to view the lower reimbursement and additional non-referred specialist fee as worthwhile, as it’s still cheaper.
“It’s not a question of access or authorization, just convenience for some patients,” Dr. Chosidow said. “The more comfortable you are, the faster you will be able to see a dermatologist — you won’t care about a small amount of Euros that you lost to book directly.” [pagebreak]
Treatment use and availability
While French dermatologists enjoy many of the same advances as their colleagues in comparable nations, there are some differences in the scope of their practice. Physicians are not allowed to dispense pharmaceuticals in the country, including cosmeceuticals. And some surgical procedures are rarer, too.
“Mohs surgery is not practiced in France outside of one or two large centers, as dermatologists in France are not taught to read slides during training. It’s just not taught in France. The one or two French Mohs surgeons were trained abroad and practice in one of these large centers,” Dr. Wallach said, continuing that the necessity of an on-hand pathologist is what limits Mohs to larger medical centers. “This makes a big difference in the treatment of skin carcinoma here,” he said: There is more curettage and dessication than in the U.S., but almost all carcinomas are treated by surgical excision.
There are also some differences in drug treatments available in France. Topical mechlorethamine is no longer available for the treatment of mycosis fungoides due to a shortage. In contrast, cyproterone acetate and anti-androgen drugs are available, according to Dr. Wallach, if not always commonly used. The treatment of scabies with ivermectin, an off-label application in the U.S., is a label-approved usage in France as deemed by the Ministry of Health, Dr. Wallach said. Approval in France, he said, functions much like the Food and Drug Administration in the U.S. Photophoresis, he said, is rarely practiced in France.
For psoriasis, etanercept, infliximab, adalimumab, and ustekinumab are part of the drug formulary, but only for cases resistant to UV therapy and methotrexate or cyclosporine. For acne, generic versions of doxycycline and lymecycline are the most popular antibiotics. Low dose minocycline is also an option, Dr. Wallach said, but is rarely prescribed because of the potential side effects.
One growing segment of medicine in the U.S. — physician assistants (PAs) and nurse practitioners (NPs) — is completely absent in France. While state laws have been updated over the last few decades to expand the scope of practice for these non-physician clinicians in the U.S., medical care by non-physicians has been prohibited by law since the 19th century in France, according to Dr. Wallach.
“We only have MDs treating patients — if you’re not an MD, you can’t care for a patient. The only allied health care worker category is midwives,” Dr. Wallach said. “For us it’s very surprising when we see what the physician assistants and the nurse clinicians can do in the United States.”
In terms of purchasing materials and updating facilities, France — and European nations in general — have a more centralized procurement process, Dr. Chosidow said. A 2012 report by Simon-Kucher and Partners found that new products are often delayed in launch compared to other countries as a result. “You have to fight a lot to try to improve the facilities, to buy a dermascope, to buy materials.”
In all, Dr. Chosidow said, French citizens, both physicians and patients, take pride in the quality of care easily available to all levels of society.
“I think that the strength of the care system is that to date, the level of care in very good in France for everyone,” he said. “The majority of the population has access to a doctor, good health, and good care, in the majority of cases and for the majority of diseases.”