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.