Advancing Primary Care in France and the United States

Abstract

Primary care has been identified as key to improving health care delivery systems across the globe. France and the United States have been ranked low on scales of primary care orientation. However, each nation has developed significant approaches to structuring primary care and organizing primary care-focused systems. This article reviews those efforts and finds that both nations face similar barriers to implementing many primary care initiatives.

Introduction

Recently, in many countries there has been a strong resurgence in interest in strengthening primary care.^1,2 This renewed interest is stimulated by arguments based on a body of evidence that a primary care-led health system is better able to efficiently deliver better health outcomes at sustainable costs than systems more dependent on hospital-focused care and specialists.^3,4 A portion of the evidence in support of primary care comes from international comparisons of health system performance.^5,6 The United States and France are considered relatively low on a scale of primary care implementation,^7,8 but there have been recent policy changes and reforms in both countries that focus on primary care.

This article describes how France is attempting to strengthen primary care in its health care delivery system, and the article draws parallels to policy changes in the United States. Efforts in the United States to promote primary care have included the development of the patient-centered medical home (PCMH) and accountable care organizations, which are built around primary care practices as mechanisms to make the system more accountable, effective, and affordable. ⁹ In France, policy makers are proposing similar entities called maisons de santé, maisons médicales de garde, “proximity care,” and “plurisciplinary” group practices focusing on prevention and chronic disease care. ¹⁰ The forces that impede their implementation in France are familiar to an observer in the United States: dominance of specialists in the development of policies to implement reforms, including the control of reimbursement and the structure of care; a hospital-centric system; and a struggle for control over payments that favor specialists.

Recent Origins of Primary Care Reform in France

In France in 1998, a voluntary gatekeeping system, the médecin référent, was implemented by the national health insurance system, the Caisse Nationale d’Assurance Médicale (CNAM), with the support of the dominant trade union of generalist physicians, MG-France. ¹¹ The scheme was abandoned, as only 10% of physicians and slightly more than 1% of patients enrolled and cost projections showed an average increase of 30% in overall payments from the CNAM to participating physicians without any significant gains in access or outcomes. Subsequently, a new preferred physician program, the médecin traitant, was passed into law in 2004. ¹¹ In this program, patients were essentially required to register with a physician—but not necessarily a general practitioner (GP)—who would then coordinate their care in the health care system. The program was considered successful, as 81% of the population complied in the first year (99% registered with a GP), a percentage that reached 92% by 2009. This success rate may have been a result of more than 80% of patients already having a “regular” doctor. ¹² After intense lobbying by specialists, adjustments to payments were made for specialties that were expected to lose patient volume as a result of the system—rehabilitative care, dermatology, endocrinology, rheumatology, and otolaryngology. The result was a complex system of fees and payments that could be claimed by the specialist receiving the referral—not the primary care physician who made the referral. This is essentially reverse gatekeeping, and the specialist is given the responsibility of coding the visit as an appropriate referral. ¹¹

The system did allow CNAM to link physicians to their patient lists using administrative data. The addition of this information backbone provided the framework for development of a pay-for-performance program called “contract for the improvement of individual practice,” which is now viewed by stakeholders as a promising vehicle to control costs, ¹³ much as pay for performance (P4P) is seen in the United States.

The Pipeline into Primary Care

Although the independent nature of practice has led to a primarily specialist-dominated system in France like in the United States, there is an important difference between the 2 in how nurses contribute to primary care. In France, the principle of “liberal medicine” is extended to other health professions in the ambulatory sector, including nurses. Independent practice nurses (75% of the 65,000 nurses practicing outside hospitals) are paid primarily on a fee-for-service basis and can exercise independent judgment in clinical decisions and choose where to practice; there have been some recently enacted restrictions on the freedom to locate. ¹⁴ The desire to retain this type of payment has already had some restraining effects on the development of primary care team projects. The nurses’ unions were fiercely opposed to the extension of a successful team-care experiment because it required salaried, as opposed to independent, nurses to be responsible for the follow-up of patients.

Both France and the United States are concerned with adequacy of the physician supply, especially in primary care. In the United States, the pipeline into medicine is effectively controlled by the number of approved graduate medical education slots. France has a very autonomous physician supply that is dependent on the number of medical students who graduate. In France, entry into the first year of medical school is open to all qualified applicants, but a strict selection process controlled by examination limits the proportion of students allowed to move beyond the first year. This numerus clausus is set by the government and is the central policy tool controlling the physician supply. The preparation of primary care physicians encounters the same barriers as in the United States. The highest scoring French medical students are encouraged to move into subspecialty tracks that are seen as having more prestige and higher incomes. Many students prefer to take an additional year of training prior to exams for a better chance to enter a specialty track. The medical school cultures in both systems continue to give higher status to specialty medicine, and the formal mentoring process dominated by specialists often pushes young physicians away from primary care. ¹⁵

Since the 1970s, family medicine in the United States has been acknowledged as a separate and perhaps the preeminent primary care specialty. Academic departments of family medicine are present in almost all medical schools. There is no equivalent in France. The academic recognition of primary care came as late as the year 2000 in France with the establishment of a “Collège” of general practice along with the creation of separate internships. These internships were led by a select number of GPs, who were named as full university professors in medical schools in 2009—a first for the specialty. The Ministry of Health has issued plans to train more than 7000 doctors per year, and the target is for 50% of them to become GPs. This goal appears unrealistic, as only 131 of 5000 academic positions in medical schools are devoted to primary care. In the fall of 2010, the French government issued a report that proposed using “medical homes” as the location for the future training of primary care physicians. ¹⁶ This report bears some resemblance to the “Teaching Health Centers” initiative in the 2010 Affordable Care Act (section 5508), which funds graduate medical education in ambulatory care sites, but its format has not been clarified.

In France, there has been little sponsored research in primary care and generalist medicine until recently. Demonstration projects of multidisciplinary team practice, such as the Action de Santé Libérale en Equipe, which is evaluating the use of a chronic care model in primary care, ¹⁷ and the Partenariat Pluridisciplinaire de Recherche sur l’Organisation des Soins de Premier Recours (PROSPERE), to demonstrate and evaluate primary care team work, ¹⁸ have been implemented in the past 4 years.

The demography of the existing primary care supply in both countries has changed dramatically and in parallel over recent years. The rapid growth of medical schools in the United States in the 1970s and 1980s stalled when there was an apparent impending oversupply, and by the turn of the century, training levels stabilized at a level that turned out to be below the replacement rate.^19,20 This situation has created a bimodal population of primary care practitioners, and a large proportion of the overall number will move into retirement age within the next decade. In France, similar trends hold, as a rapid growth in the overall supply of physicians in 1970s and 1980s was followed by a reduction of the numerus clausus, resulting in a shortage of generalists and specialists. Both countries now face a decline in the number of physicians that may prompt further support for primary care programs.

Financial Incentives

The United States has a complex mix of payment structures, still dominated by fee-for-service, that shapes medical care provision, and its various elements can either promote primary care or punish it. ²¹ The “relative value” payment structure used in Medicare has become the template for calculating payments for services but does not strictly set prices. The United States has adopted a current procedural terminology list, which narrowly defines each service based on a complex division of tasks that is skewed toward specialty care because of the multiplicity of procedures that can be defined in specialty care and the relatively broad scope of primary care activities that fall under less specific “evaluation and management” codes. There have been efforts in recent years that have attempted to shift the emphasis and relative weights—which control payments—away from procedural care, to the “evaluation and management” activities or “cognitive” care provided by primary care practitioners.^22,23

The same trend can be seen in France, where prices are determined in a system also based on relative value units (RVUs). The French equivalent to current procedural terminology is the catalogue commun des actes médicaux, which shares the same tendency to enhance payments for specialists. Generalists are paid using a separate procedure list issued by the CNAM, the nomenclature des actes professionnels, which does not take into account clinical complexity. The emphasis on fee-for-service has sustained the imbalance in the revenues of generalists compared to specialists. Generalists (omnipraticiens) make approximately 60% of what specialists earn on average, €67,000 versus €109,000 per year. ²⁴ A 2009 report commissioned by the French health minister found “strong disparities among disciplines in payment” that created “tensions” among specialties and constrained their ability to coordinate care. ²⁵

Both nations are seeing a growing geographic imbalance in the supply of physicians, leading to shortages or complete absence of physicians in specific areas.^26,27 According to an assessment by the CNAM, policies that relied on monetary incentives such as fee supplements and bonuses yielded little in France. This is also the case in the United States, where the Medicare program gives a 10% bonus for physicians practicing in designated underserved areas but has only a marginal effect on location decisions. ²⁸

The Organization of Care

Group practice is widely accepted in the United States and is also viewed as a key element of the patient-centered medical home and the newly proposed accountable care organizations included in the Affordable Care Act (ACA).^29,30 Group practice is not as well recognized or regarded in France. Schoen et al reported hat French physicians had low participation in groups and relatively low involvement with electronic medical records, chronic disease protocols, and adverse event reporting. In the same vein, a 2009 report commissioned by the Ministries of Health, Education, and Labor pointed out that few financial or technical mechanisms existed that could support the development of multidisciplinary care in medical homes or primary care centers. ¹⁰

This view of France as antagonistic to primary care and reliant on mostly independent physicians to provide primary care does not agree with more recent data coming from studies done within France. Based on a representative sample of primary care doctors, involvement in group practice was found to be much more widespread; more than half of all French GPs (54%) work in group practice—a substantial increase from 42% in 1998. ³¹ A companion study evaluated the maisons de santé, or “health homes,” that were multidiciplinary teams independently developed by community-based generalist practitioners. The health homes were shown to provide greater access with longer opening hours, broader provision of care and preventive services, and they provided an example of efficient cooperation between professionals from different disciplines. Team care is also a required characteristic of the proposed PCMH in the United States and is emphasized in many descriptions of primary care-led systems. ³²

There are recognized problems in the US medical system in continuity of care and coordination of services.^33-35 These deficiencies are frequently interpreted as a failure to make effective use of primary care practitioners. Physicians in the United States are much less likely to provide after-hours care in their practices (29% compared to 78% in France). ⁶ France has encountered similar problems and has developed its own solutions to manage continuity and coordination of care under a concept labeled permanence des soins.

France operates a mixed system for urgent and emergent care based largely on generalists. The emergency care systems are coordinated by a communications network that links patients to “urgent” care providers such as SOS médecins, which operate in some but not all cities in France. The CNAM master contract with physician unions includes provisions that require GPs to provide urgent care after regular office hours. In the late 1990s, GPs protested the low payments they received for after-hours care and began to withdraw from 24-hour duty, and the system has become more and more reliant on public hospitals and emergency rooms. The maisons de santé are considered 1 solution for providing after-hours primary care.

Electronic Information Systems

A strong electronic record system that supports the coordination of care and assessment of population health is considered a necessary element of optimally effective health care delivery systems. ³⁶ Electronic medical/health records and robust information systems are seen as 1 way to bolster the place of primary care in the United States by empowering the practitioner with a coordinating role in the system. ³⁷ France has set similar goals for information technology in health but has run into many of the same problems that the United States has encountered. In 2004 the Ministry of Health launched an initiative that was supposed to cover all French territory with electronic medical records in a 5-year period. This proved to be an overly ambitious goal, and the program has now been restructured in a more conservative and pragmatic manner and is moving, but at a much slower pace. ³⁸ In the meantime, the CNAM has extensively developed its own information system; however, the system does not contain extensive clinical data, only medications and the services that are provided. The CNAM is determining how to merge their administrative data with clinical data coming from a sample of GPs as part of the PROSPÈRE demonstration project. ³⁹

Current Policy initiatives to support Primary Care

The French government is sponsoring new methods to pay for services (évaluation expérimentations de nouveaux modes de rémunération) that lean heavily on primary care principles. The initial target of 50 medical homes has been expanded to 250, which are to be established over the next 3 years primarily in deprived areas. Meanwhile, the CNAM is making use of the médecin traitant system to implement changes such as a disease management program called “Sophia” that is focused primarily on diabetes prevention using the Chronic Care Model and other US-based prevention and management programs. ⁴⁰ The project relies mainly on nurses working from call centers to manage patients after assignment by the médecin traitant. The program aims to reach 136,000 patients and 6000 GPs in 10 different departments by the end of 2010. ⁴¹ The CNAM has also has introduced (2008) an individual pay-for-performance program (contrats d’amélioration des pratiques individuelles) that contracts with médecins traitants to meet certain prevention, prescription, and chronic disease management goals in exchange for achievement bonuses paid to the doctors. The first results of this has program have shown that some physicians have enhanced the quality of their practice quality with no net increase in cost to the CNAM. ¹³

France also shares many common characteristics with the United States that are relevant to primary care: a reliance on independent medical practitioners, a mixed form of financing, overall organization that favors hospital-based care, and a separation of roles by profession and discipline. ⁴² In order to address these issues, both countries see budgetary pressures as offering an opportunity to reform their systems by implementing, in a piecemeal approach, multiple reforms, many of which focus on strengthening primary care.