France is a good place to be sick

As you may have seen in Sicko, the basic French medical system is very nice with lots of publicly assisted services. Its quality is enhanced by the fact that a lot of its services are available with upgrades outside of the strictly public structure. This means that instead of a single-tiered, state-provider, there is are a lot of options, all of whom can count on the state medical fund to provide the core reimbursement.


This principle is everywhere. I know several people who have their kids in "Catholic" school. It is run by the church but there are not many nuns and monks teaching there now. They do get the bulk of their budget from the state in proportion to the number of students just like they were a standard public school and who add their extra bit by charging a really reasonable tuition (something like $3,000 - $5,000 / year). They do it to increase the chances of their children getting into one of the "grandes écoles"; I would do it too. All the schools have to teach certain subjects and enforce separation of church and state. They all teach evolution. Even though it seems odd for such an atheistic society, I think the Catholic schools can have catechism. It is an old deal between the church and state. The 'private' schools are expected to go the extra mile in caring for the academic development of the students, and I think that for the most part, they do.


Back in the health care system, this means there are public hospitals, private "cliniques", and non-public hospitals. The public hospitals are institutional things that provide some amazing experiences but do not seem to accomplish many amazing things. They are inhabited by large numbers of public servants who have signficant entitlements in the form of time-off, breaks, and other perks. They "serve" the public at relatively low cost. Because of general French edginess, I think they manage to be safer places than American public hospitals, but the word here is don't take your kids there.


The "clinique" variety of establishments seem to be mainly money-making propositions that are still a great deal for doc-in-the-box needs. They typically use free-enterprise and economies of scale to hammer down costs and figure ways to offer a host of services including hospitalization. My first urologist was in the Clinique du Parc Monceau, and if I had not explored other opportunities, I could have walked to and from my operation. I got an ultrasound there as well as my biopsy. The doctors use the facilities and charge patients directly for their work. The clinique gets a cut in the form of rent for the offices and helps the doctors with scheduling appointments and communicating with patients and others. It is reasonable in cost. They typically have their own medical labs, but independant medical labs are easy to come by. I think their limit lies in the higher ranges of medical practice, which do not come into play so often. I have not found our dealt with a giant one that has high-end surgical or cardiological units, but I guess that could exist, but the formula of the non-profit hospital seems much more adapted to that.


The non-profit hospital solves a tougher set of problems. The formula is well-known in American medical circles with at least the Mayo and Cleveland Clinics. It addresses a lot of needs at once, but the basic problem is how to make the best treatments available for people that need it, especially in the case of life-threatening conditions.

In France, these hospitals increase the number of people who can take advantage of the best science needed for their problems. The two non-profit hospitals I have had some experience with are (http://www.imm.fr/) and the American Hospital (http://www.americanhospital.org/). These hospitals work with the big French mutual insurance companies which I understand operate on top of the French health care system. Like the Catholic schools, they get their money from the health care reimbursements and supplement this with funds from the mutual.

It is the same logic as with the schools. The state reimburses for customary and reasonable expenses within its system. The system is called la Sécurité Sociale. This is a great thing for people with no means, because it assures a minimum level of health care for others. The mutuals are these big non-profits to which people can belong that make up the difference for additional levels of care or quality. Most people who have a job have some sort of "mutuelle" that gives them access to this top-level care.

Doctors and clinics can choose to be or not in the "système". If you are not in the system, that means that you are counting on a a slightly better-off clientele and especially people who have a "mutuelle" at work. They still have to deal with the mutuelle for reimbursement, but they can charge more. Some doctors charge even more and the patient is left having to pay the difference. This is pretty familiar to Americans.

In a simple version of this, my personal care physician is a English woman who treats anglophones in English at "not-in-the-system" rates which are a bit more expensive than regular doctor fees. Not in "le système" means basically what the market will bear using mechanisms that are like U.S. medicine. In her case she commands a bit of a premium, a fair market value to us to be able to speak our native tongue about problems that can be hard to explain in French. The dentist in our building is known among our fellow Americans as a "good as an American dentist". He gets a whopping premium (>$200 for a cleaning) , our insurer does not reimburse it, and we don't use him. He is very nice and we chat with him when he walks his dog: "Bonjour, Monsieur."

There is some difficulty when American insurers and European health-care providers meet. I have an American insurance that reimburses for non-American medical expenses. Many times, the result is fine. Simple doctor visits, prescription drugs, are generally cheaper than the U.S. even at big euro exchange rates, so reimbursement is not a problem. I have continued to use my U.S. dentist, because he is good, has not gone in for profiteering from my boomer dentation, and I visit our home enough to see him. But around me in France I hear much anxiety about teeth. French do yet not seem to view regular dental care as part of the French medical entitlement, and I think that dental anxiety is probably why. The French are smart and love thinking ahead, so they will eventually get it about preventive dental care, but for now, what is paid for is when you have cavities and worse dental problems. In other words, once real problems have started.

I have always loved French doctors because they are so *normal*. Many French doctors are living on the equivalent of an engineer's salary or less. You go to a doctor's office, and there is a nice waiting room, but none of the staff you usually see in the U.S. When he or she is ready for you, someone else usually comes out followed by the doctor who invites you in. Most of the general practitionners I have visited work *alone*. I think they generally have an accountant and maybe an answering service, but otherwise, they cannot afford the rest. If they are in the system, they know what every consultation will bring in from the state and what they are going to charge you, which is 5 to 10 euros. The specialists are usually doing anywhere from a little to quite a bit better, but I have yet to meet the equivalent of the E-Room doctor from our old home town hospital that built a Million $ home out in the county four years after he started there..

The hospital that treated me is the Institut Mutualiste Montsouris. It was founded at a center of excellence, and operates within the scope of an association of mutuals for the public good (link). Each department has a lot of power to manage its team and develop its offerings. Since opening, the urology department has become truly pre-eminent in laproscopic radical prostatectomies like the one I had. I did not get a number, but one of the doctors told me that I was going to having around the 4000th LRP.

This facility is even known in U.S. medicine: see history in the following link. But getting insurance coverage here turned into a bit of an ordeal. That will be in another note.

It's not the technique, it's the surgeon.

It is so interesting what happens when people move and need to go the doctor or dentist again. Lots of times, they get in the car or airplane and make their way back to the people they trusted near their old homes. I can certainly understand them. I have never been viscerally attracted to the French medical system, but this experience got me a lot more familiar with it. First of all, the number of times you need to spend time with the medical community is a lot greater when you have a "condition" than when you have the flu or get a sore throat, and when you are going to get surgery, for something, you need to pay close attention to the talent pool. For prostate surgery, all of the American surgeons I consulted with emphasized that this is about finding an experienced and accomplished surgeon.

How does one become one? I think the answer is apprenticeship with one that already is. In any case if the surgeon is not doing at least 100 or more a year with a good track record you might want to keep shopping.

The other thing is statistics. Gerald Chodak states the matter clearly in his video about laproscopic and robotic surgery techniques. If they cannot talk serious statistics, it is another bad sign. I am a little sheepish about the fact that I do not have my specific doctor's statistics, but I do have the numbers for his whole organisation, and he is the senior active surgeon there.

Approval

I finally got the approval from American insurance for the surgery. Glad I started pushing for this a while back.

I do feel fortunate.

Grimy stupid money

After his extraordinary blaze of literary glory, Arthur Rimbaud took off for adventure in first in Java and Cyprus then in Africa and basically did pretty well as an entrepreneur / adventurer until he got cancer and ended up pretty much misunderstood and mistreated by the medical systems of the time. I am still agonising over how my operation is going to be paid for. The people at the end of the line are "supportive" but not answering the big question yet.

In alt.support.cancer.prostate, there is a posting about Dana Jennings. His writing about PC seems on target to me.

Going forward with the operation

Well, I am on for the Institut Montsouris. It just looks like the best option. There are some excellent possiblities in the U.S., but all indications are that Montsouris is a master of the laproscopic radical prostatectomy. Its outcomes really look good, and my insurer appears to be ready to reimburse for this treatment. We will have to come up with the initial funds and then apply for reimbursement.

The financial side of this business is a bit obscure. There are two big factors that I see:

• Providers do not want to divulge much about the costs until they know that all they have to do is bill you. No one wants to dicker. The patient really does not want to, because what he cares most about is getting well. The medical providers do not want to talk too much because they do not want to get into a situation of competition or bargaining because of the second reason.
• American (and probably overseas) insurers whittle away at the costs, imposing "customary and reasonable" billing expectations that only doctors, hospitals and their business managers are likely to see. I have no idea what that does to the real cost profile, but I am sure that there are some major variations in the final costs from operation to operation that have nothing to do with the degree of difficulty or outcomes.

I have had one excellent doctor indicate that I should communicate my insurance information and let him tell me how much out-of-pocket I can expect. Now that's a fine entrepreneurial proposal. Others were more forthright with a number, but it either took a lot of digging or I had to tell the provider that I was looking for a lump-sum number on the basis of coming to their center from overseas.

I am going to do a separate entry devoted to costs that I will update as this thing plays out.

I am hoping that things could work out that the Institut Monsouris will be able to handle my case pretty quickly. I think I still have time to get surgery with a pretty good chance of cure. The good news is that my endorectal MRI will be done there in advance of a meeting with one of their surgeons.