Wednesday, 17 December 2008

There's no such thing as a free lunch

In comparative studies of different countries' healthcare, France consistently comes out near, and often at, at the top. Waiting times are almost non-existent, technical expertise is at a very high level and the system is largely based around choice: the patient's choice of which doctor or specialist to see, and the doctor's choice of treatment, largely unconstrained by cost factors. Need an operation? The chances are you'll be offered it next week. Need an injection? No problem; the nurse will come to your home and do it, this afternoon if you like. Need an unusual (and expensive) drug? That's fine too - no postcode prescribing here. As a result the vast majority of French people pronounce themselves to be very happy with their healthcare, and boy, do they use it! It's fully expected here that you'll visit your medecin traitant (GP) for even the slightest symptom - sore throat, cold, headache, indigestion, sleepless night, itch in a strange place ... and over 94% of GP visits here result in a drug prescription. Indeed they're generally considered ineffective unless they do so; the average French household has cupboards full of half used or even unused medications. The fact that I haven't seen a doctor for some twenty years (and have no desire to do so for at least another twenty) provokes at first hilarity, and then - when they realise I'm serious - out and out horror amongst French acquaintances and friends. 

The upside of all this is that the French can expect to live longer, and more healthily, than most people who live elsewhere. The downside? Well, cost, of course. Unlike the UK, the French health service is not free at the point of delivery; it has always been partly contributory. All working people, and their employers, pay hefty cotisations (contributions) towards their health care. The state then covers a certain percentage (ranging from 15% to 100%) depending on the type of treatment, with  the balance being paid directly by the individual either out of their own pocket or through a 'top-up' complementary health insurance policy. But the French healthcare system is still one of the most expensive in the world to run, with a current deficit of over 4 billion euros. (It would be more expensive still if doctors were paid anything like their counterparts in the UK, who now receive salaries of which the French can only dream ...). And I'm beginning to see why.

If you've been reading this blog for a while, you might remember that earlier this year John had a close encounter with the health system here in the form of a stay in a Toulouse hospital (cost to the Social Security system / our top-up insurers: a mere 1196 euros a day - nearly fifteen thousand euros in all. And that's without surgery ...). All has been well since then, but a couple of months ago it was suggested he go back for an 'MOT', which in his case comprised 10 hours in the Hôpital de Jour being subjected to no less than 23 different tests on every conceivable part of his bodily functioning, arteries, kidneys etc, with breakfast, lunch and goûter thrown in alongside sessions with several consultant doctors. Cost to Social Security / top-up: 940 euros. It's the kind of thing that belongs firmly in BUPA territory in the UK, but perfectly normal here. On the day before this marathon, he'd had to present himself to yet another department for the fitting of a Holter ambulant blood pressure monitor (don't ask); while he was there, the doctor announced that they were 'just going to do one test that day instead of the next' and that 'we've ordered lunch for you'. Test was duly done, and dusted, all within 30 minutes, lunch was duly declined (if you ever have the misfortune to stay at CHU Rangueil you'll know why).

One of the administrative strengths of the French health system - and heaven knows there aren't many: it's as cumbersome as a cart horse - is that you always know exactly how much each element of your care is costing, because you get a bill for it. We were, shall I say, a little surprised then when the bill arrived for the Holter day and it was - wait for it - 940 euros ... the full day rate. Hmm. I thought about this one, and smelt a scam. Not a scam on us, because 80% of the bill was covered by Social Security, and the remaining 20% by our top-up. But a scam by the hospital to - how can I put this? - maximise its income. By shifting one short test a day forward, and providing lunch, the hospital reckoned it had justified charging the 940 euros day rate instead of the appropriate costs for one consultation and one test - 75.60 euros, to be precise.

So I decided to call it. I wrote to the Director of the hospital, suggesting (with the utmost politesse of course) that an "unfortunate error must have occurred". I copied the letter to our local Social Security office, to the consultant-in-chief of the day hospital, to John's medecin traitant. "Bof!" said my neighbour. "Why bother? It's normal. Sécu have paid it already [they had]. In any case, you'll never win". But do you know what? I did. No letter, no acknowledgement even. Just a revised bill. In the great overspend that is the French health service, it's not even a molecule in the ocean. But I feel better for it.

You see, it's true. There really is no such thing as a free lunch. 

1 comment:

Cristina said...

I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.


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