why does france have the best healthcare system

ACHIEVEMENTS, PROBLEMS, AND REFORM
The French health care system delivers a higher aggregate level of services and higher consumer satisfaction with a significantly lower level of health expenditures, as a share of GDP, than in the United States. Add to this the enormous choice of health delivery options given to consumers, the low level of micromanagement imposed on health care professionals, and the higher level of population health status achieved by the French, and some would argue that the French model is a worthy export product. Others, however, would emphasize the problems that accompany this model. First, despite the achievement of universal coverage under NHI, there are still striking disparities in the geographic distribution of health resources and inequalities of health outcomes by social class. In response to these problems, there is a consensus that these issues extend beyond health care financing and organization and require stronger public health interventions. Second, there is a newly perceived problem of uneven quality in the distribution of health services. In 1997, a reputable consumer publication issued a list of hospitals delivering low-quality, even dangerous care. Even before this consumer awareness, there was a growing recognition that one aspect of quality problems, particularly with regard to chronic diseases and older persons, is the lack of coordination and case management services for patients.


These problems are exacerbated by the anarchic character of the French health system what might be called the darker side of laissez-fair e. Third, although, compared with the United States, France appears to have controlled its health care expenditures, within Europe, France is still among the higher spenders. This has led the Ministry of Finance to circumscribe health spending since the early 1970s. Much like the prospective payment system for Medicare in the United States, France has imposed strong price control policies on the entire health sector. Greater cost containment has been achieved through such controls in France than in the United States. Although the level of health services use is high in France (Table 3 ), prices per service unit are exceedingly low by US standards, and this has led to increasing tensions (physicians strikes and demonstrations) between physician associations and their negotiating partners the NHI funds and the state. The allowable fee for an office visit to a GP, for example, is only 20 1, and one half of all French physicians are GPs. Physician specialists also receive low fees (23 1), except for cardiologists (46 1), psychiatrists (36 1), and those who do not accept assignment. The $55 000 average net annual income of French physicians salaried hospital-based doctors as well as GPs and specialists in private practice is barely one third that of their US counterparts ($194 000) (C. LePen and E. Piriou, written communication, August 2002).


In addition to price controls, capital controls on the health system are stringent. They include limits on the number of medical students admitted to the second year of medical school, controls on hospital beds and medical technologies, imposition (since 1984) of global budgets on hospital operating expenditures, and the more recent Jupp plan that imposed annual expenditure targets for all NHI expenditures. Prime Minister Jupp s plan and more recent reforms have addressed the problems noted above; none of them, however, have been solved. The Jupp government established a slew of national public health agencies to strengthen disease surveillance and monitor food safety, drug safety, and the environment. It organized a new national agency, the Agence National d Accr ditation et d valuation en Sant, to promote health care evaluation, prepare hospital accreditation procedures, and establish medical practice guidelines. It also set up regional hospital agencies with new powers to coordinate public and private hospitals and allocate their budgets. In addition, the Jupp plan included measures to modernize the French health care system by improving the coding and collection of information on all ambulatory care consultations and prescriptions and by allowing experiments to improve the coordination of health services.


This represents an emerging form of French-style managed care a centrally directed attempt to rationalize the delivery of health services. The institutional barriers to such reform are considerable, but whatever transpires in the future, the French experience with NHI may be instructive for the United States. It s not uncommon in the bigger cities, particularly in Paris, for a doctor to charge more than the government s recommended price. But these overages, called d passements, don t come anywhere near what an American specialist might charge. In fact, under French law, a doctor must issue a receipt explaining any d passement above 70 euros before beginning the test or appointment. (France is also arguably more creative than U. S. health care providers in keeping childbirth costs down. For example, women who are likely to have complication-free births are usually referred to a Level 1 maternity ward, which has an operating room in case a C-section is necessary but no neo-natal unit or full hospital facility attached to the clinic. In the U. S. , most women deliver at a full-service hospital, even if it s likely they will experience no complications. )

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