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Medicine in Social Security in France

31 Mar
France Télévisions

France Télévisions (Photo credit: Wikipedia)

In this video:

In vivo, l’intégrale – – voir ou revoir les programmes de france télévisions – France Télévisions.

is described the every day life of workers in France exposed to occupational diseases and injuries. The Social Security schemes intend to compensate the disabilities that stem from work. But sometimes the worker must struggle against a rejection of his demand by the Social Security administration. In that case the dispute is judged in front of the Court of the Dispute of the Incapacity (Tribunal du Contentieux de l’Incapacité or TCI) which is a specialized court in charge of social benefits litigation. The Musculoskeletal disorders (MSDs) take a huge place in the mechanism of such disabilities. In some cases the workers victimized by an occupational injury have to justify their request as if they were exaggerating their sufferings. The liability is thus reversed and it is not fair in my view.


The overtreaters

22 Feb

When all you have is a hammer, everything looks like a nail.

Patient Recognition Month Poster

Patient Recognition Month Poster (Photo credit: Army Medicine)

President of the Conseil National de l’Ordre des Médecins, the French national board for private practice physicians, has said in a recent interview on the topic of breath cancer screening: “one would better have too much chemotherapy than not enough”. This statement from a French health policy stake holder could hint that France is not enough mobilized against the issue of over treatment, unnecessary treatment and non pertinent treatment (although other stake holders are aware of the problem as shown in the document, issued by the former National Physician Adviser of one of the greatest health insurance scheme of France, entitled “Pertinence des actes par delà la polémique” cited in the work consulted list below).

Yet the pertinence of a treatment is a very relevant issue that health insurance companies have to deal with, be they private or public. A great amount of literature has already been released treating of the subject and health insurance policy makers are more and more concerned in the hope to cut some spending and improve the quality of care all in a same move by addressing the issue of overuse of medical care.

Unfortunately, to distinguish which procedure is really needed from which is non relevant requires, when it comes to a single patient, a high level of medical expertise and skill all along associated with a very high responsibility in case of misjudgment . That’s the reason why the better way for the health care benefits manager to solve the problem is to ask for a second medical opinion. And that’s how an almost patient is transformed in a non patient at all. Using such a procedure a benefit manager glorifies himself having avoided to a dozen of his insured the bistoury of their surgeon.

If a surgeon appears to show a high trend to operate although there is no particular need, the benefit manager enlist him in a “do not use” list. Four procedures are now under high scrutiny in the US: Stents for Stable Angina, Complex spinal fusion for stenosis, Hysterectomy for uterine fibroids, and Knee arthroscopy for osteoarthritis.

Surgeons are not automatically guilty of a willing of harm their patient but the bias can be resumed as follows: “when all you have is a hammer, everything looks like a nail”.

But surgeons are not alone exposed the trend of over treating. Pharmaceutical firms try systematically to open new market shares either by widening the indication of an old molecule with large and expansive multicenter studies or by widening the field of extension of a common disease which was not very known by the public and the health care providers until the drug maker undertakes a nation wide disease mongering campaign. And as Richard Lehman notes in his Blog post of February 20th2012, pharmaceutical companies are ready to put a lot of money to do that: “It took 60 centres in 11 countries to recruit 227 subjects for that PRIMO trial of paracalcitol (“Zemplar,” Abbott). This is not at all unusual in trials run by pharmaceutical companies on products still under patent, when the prize might be a large extension of indication.” Unfortunately for the company, the results of this large multicenter study were negative while a more modest less funded study showed that amoxicillin shorten by only three days the course of  acute rhino sinusitis versus placebo.

And my conclusion will be: in medicine “the more the better” is a maxim that has to be pronounced cautiously.

Works consulted:

1) Keep your docs off ‘do not use’ lists

2) Four surgeries to think about avoiding.

3) White Coat, Black Hat: Adventures on the Dark Side of Medicine.

4) Take patients away from the overtreaters.

5) Quant aux chimiothérapies, il vaut mieux en faire un peu trop que pas assez ! affirme le docteur Legmann, Président du CNOM.

6) The Treatment Trap: How the Overuse of Medical Care Is Wrecking Your Health and What You Can Do to Prevent It.

7) Amoxicillin for Acute Rhinosinusitis; a Randomized Controlled Trial

8) Vitamin D Therapy and Cardiac Structure and Function in Patients With Chronic Kidney Disease; the PRIMO Randomized Controlled Trial

9) Richard Lehman’s journal review – 20 February 2012 by BMJ Group

JAMA  15 Feb 2012  Vol 306

10) Fait-on trop de dépistage du cancer du sein ?

11) Pertinence des actes par delà la polémique; le regard de l’assurance maladie.

Le quotidien du médecin

10 Jan

Today is a celebration day. One of the most read daily medical news-paper in France, especially by general practitioners, has just quoted, in its January 9th, 2012 issue, the Health Services Authors blog.

The author of a letter published by the Quotidien du Médecin, Dr Olivier Guilhot, a general practitioner giving primary cares in a disadvantaged suburb of Marseilles, made a reference to two posts of the Health Services Authors blog: this one and this one.
I’m very pleased that this blog could be used as a material in an interesting debate about the risk of moral hazard attached to the declarative side of the financial incentives attribution procedure in the brand new P4P implemented in France last summer. This is the mission statement of health services authors blog to participate and fuel all the discussions in the health services policy provided that they are grounded on sound research results. If I do not endorse the entire contents of the letter nevertheless I was sensitive to some very stylish excerpts like for example the evocation of the ghosts of fathers of the social security system in 1945 (now all dead), victorious of the Nazis, inheriting the solidarity spirit from the concentration camps, assisting to an actual meeting and standing up and leaving the assembly when hearing a health care provider saying that it’s just sufficient to declare you succeeded the objectives to receive the financial incentive. I know the great majority of my colleagues are not that greedy. But here we touch the critical point: the moral hazard like insurers say.


28 Dec

A Christmas Sciatica

Tarlov's cyst, MRI

Image via Wikipedia

During the night of December 24th I incurred a terrific backache which made me to experience the efficacy of the emergencies services in Marseilles. The pain was so intense that I asked my wife to dial the 15 (emergency phone number across all the France’s territory). They sent me (at five o clock in the morning of December 25th, Christmas day) a Doctor who injected me Bi-prophenid and Myolastan). After his departure, the pain increasing higher and higher and my left leg becoming insensitive I took myself the phone, dialled the 15 and asked to the physician regulator to send me an ambulance to transport me to the emergency room on the basis of neurological symptoms.  A crew of firemen of Marseilles arrived in about 10 minutes of time and transported me in a chair down my apartment (I was totally unable to walk) in to their fire department vehicle and to the neuro surgical emergency of the Timone university hospital.  I had in emergency an MRI (very sophisticated magnetic imagery, better than scanner). I was examined by an intern in neurosurgery. Pain was released by perfusion of analgesics and anti-inflammatory drugs (thanks to Big Pharma) during the day and the following night and no longer than the next day I was examined in my public hospital bed by the Professor Fuentes a Key Opinion Leader in Neuro surgery who diagnosed a 3/6 paresis of my left foot but no need of surgical intervention if no aggravation occurs in the following 24 hours.  I discharged from the hospital December 27th and was bring back home by a light sanitary vehicle. My sentiment after this event is: yes we have the best health care system in the world, but also the best health insurance system in the world (I had absolutely nor bill neither fee to pay). And I’m proud of it. Perhaps France is indebted but if it is for such results in term of care (same thing in term of child’s education or public transports), the money we have borrowed was not spend in vain. For now on I am on work loss with income compensation benefits.  I still have difficulties to stand up or to sit down for long periods or to walk for a distance. If my employer read this post I want him to know that I wrote it lying in my sofa with my laptop computer;-)

Performance Measurement

19 Dec
English: California OPA Health Care Quality Re...

Image via Wikipedia

Converting Practice Guidelines Into Quality Measure

Performance incentives have been recently adopted in France by the national health care insurer to remunerate French Doctors. In Health care, when one can not measure outcomes one measures process. But a good process for an individual patient doesn’t reflect necessarily a good process for the average patient studied by the evidence-based medical research. In a precedent post I presented what the heterogeneity of treatment effect means. In the present post I will try to highlight where stands the fundamental difference between professional guidelines and quality assessment tools of physician practice. Guidelines stem from the average patient. A quality assessment tool assesses the individual patient dealing with the heterogeneity or deviation around the mean value. From now on, given the use of guidelines made by health policy makers to evaluate health care professionals, it becomes a priority goal for searchers to take into account this use when writing their guidelines. For that purpose they should more insist on the heterogeneity of their results and perform sub group analysis across the different risk level of disease to which their studied subjects are exposed. They should accurately determine if their recommendations are applicable to subjects with multiple co morbidities. That is only at this condition that guideline will coincide with a sound balanced quality assessment tool for physician practice.

The thoughts here above were inspired to me by the reading of the two following interesting papers authored by physicians working for the Department Veterans Affairs which manage the most important health care system in the United States:

Garber AM. Evidence-Based Guidelines As a Foundation For Performance Incentives. Health Affairs. 2005 Jan;24(1):174-179. Available from:

Walter LC, Davidowitz NP, Heineken PA, Covinsky KE. Pitfalls of Converting Practice Guidelines Into Quality Measures. JAMA: The Journal of the American Medical Association. 2004 May;291(20):2466-2470. Available from:

Work related mental disorder

29 Sep
Regions of the brain affected by PTSD and stress.

Image via Wikipedia

Work related mental disorder can be recognized either under the accident at work compensation scheme or the occupational disease compensation scheme said the last report of the European Forum of Insurances against Accidents at Work and Occupational Diseases dated February 2004.

Voluntary Violence at the workplace become more and more at stake. For example retail trades, often paid in cash, are targeted with weapons. This result in a long duration work loss for post traumatic stress disorder, and an increase  of daily compensation wages for health insurance funds. In an other hand, burn out caused by work overload  is also often seen, with a similar result of work related mental disorder.

Sunshine act

21 Sep

France is implementing the equivalent of the Sunshine act contained in the US affordable care act. Physicians will risk to be sued if they don’t disclose their links of interest with industry, would they work for medical research or continuous medical education. The spirit is US imported because French have been until now very reluctant to speak about money and revenues. In an earlier post entitled “Dollars for docs” we have discussed the way American deal with it: a total accountability.  But it is not a desperate case for the French touch: the law includes a welcomed exception:  “normal working relationships” (relations normales de travail) should fall out of the scope of the law . Further more, last but not least, by which mean the disclosed links will be published is not fixed for the moment. The journalist of “Policy and Medicine” concludes his article with this wise sentence, reflecting his deep knowledge of France: “The French are not known for such drastic measures, it is almost certain that whatever they adopt will be changed to a form that works best in the French system. ”

Barack Obama signing the Patient Protection an...

Image via Wikipedia

An angry health services author

15 Sep

Dr Braillon

Read this heartfelt essay from a Public health author from Amiens (France). Reviewing a book written by Professor Rodwin, Dr Braillon (click on his name above) draft a disastrous situation of public health in France with regard to a credibility crisis. He emphasizes the necessity of a “No free   lunch” and “healthy skepticism” attitude. He is warning us against cupidity and ignorance.


31 Aug

We give birth too much

We live too long

We do not work enough

But luckily we work smart!

It does sound like a lesson for the rest of the World to learn, doesn’t it? specially for those countries which happen to be workaholic.


30 Aug

Pharmaceutical firms as well as Big Health Insurance companies are afraid of comments on their Facebook pages. Pharmaceutical firms close their Facebook account and Health care insurers don’t even dare to open one, because they are reluctant to angry comments from their enrollees. We advise them: don’t fear Facebook, learn to use it.

But organizations, like Pharmaceutical firms and Health Insurance companies are, believe deeply in hierarchical links while Facebook don’t even know the meaning of the word “hierarchy”. Facebook produces typically horizontal linkages.

These organizations prefer undertake expansive opinion polls or surveys on random sample of customers whereas reading Facebook comments should have given them, if well analysed, the appropriate qualitative information they were searching for.

But that’s the way the world goes!

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