Semi-OT: a few notes on the French health care system (Fw: Down for the Count)
Megan Arnold
Sent: Monday, March 18, 2024 4:02 AM
To: em...@hotmail.com <em...@hotmail.com>
Subject: Down for the Count
Ever since coming back from our trip (don’t worry - part 2 is coming up) I’ve been woefully under the weather.
Usually colds and maladies last about a week, but this one is hanging on. My doctor told me there are lots and lots of viruses going around right now, and she also told me to test for Covid. Thankfully I was negative but whatever I have has worn out its welcome. Romain has also caught something different than what I have, and my two-year old Macbook Pro was given a terminal illness diagnosis by the Genius Bar the other day, so there’s been a slow-down here regarding work while everyone (and every thing) works on getting better. Yesterday a doctor came to our apartment—yes, in France, there are organizations of doctors who make housecalls, such as SOS Médecins and UMP. You can also go on Doctolib and find a doctor using the search filter for same-day availability or to find one that’s has an opening in the next three days. Most people in France have a designated médecin traitant (primary care physician), but they aren’t always available and sometimes you need medical care right now, such as on a Sunday, rather than a week from now.
Doctolib has been a game-changer in France for getting doctors appointments. Before it came along, you’d spend quite a bit of time on the phone trying to get through to your doctor (many doctors in France don’t have assistants or receptionists, and their offices are in apartments) and while France tried for years to come up with an online appointment system of their own, Doctolib did it well. Some doctors don’t want to be on it for a variety of reasons; Some say it’s capitalistic as it’s a private (French) company and not part of the French health care system. Others don’t want to pay the fees associated with being on it. A few alternatives have sprung up, such as Maiia, but Doctolib does the job so well that it’s hard to compete. Another upside to Doctolib is that you can upload all your health care documents so they’re all in one place, which you can send to your doctor, although France has come up with a similar system, MonEspaceSante.fr, and in the latter, you can choose to share that information with your medical providers, or not, to comply with the strict medical privacy laws in France. (However there was just a health care-related data breach in France, not related to the apps, and the data of up to 33 million people, about half the population of France, may have been compromised.)
Unlike the U.S., when you get an x-ray, MRI, scan, or have a blood test in France, it’s you that keeps the results and x-rays, not your doctor. So you have to have a system for filing them, and you’ll have to carry them around with you to various appointments. The French health care system is considered one of the best in the world but it comes with quite a bit of paperwork, and there’s a lot of organization involved. I had minor surgery in the Fall and spent days organizing all the paperwork, downloading documents, and had to submit justicatifs, proof on paper, to various organizations and clinics in advance, before I could have the procedure. On my morning of arrival at 7am, the intake nurse told me I couldn’t have the procedure because I was missing a piece of paper. After frantic calls to the doctor, the doctor informed me that she’d alreadly sent it via email, which the person at the clinic couldn’t comprehend. In spite of modernizing the system, many people aren’t used to anything digitized and will insist on actual paper. Employers and self-employed people pay into the Sécurité Sociale system (which is not the same as Social Security in the States), in what are known as “social charges,” which can be hefty, but everyone in covered. If you are a French resident or citizen, you have the right to healthcare. It’s not a political issue in France. However the system runs at a pretty large deficit (for 2024, that estimate is €15 billion) and there have been severe cuts to the system, and there are active debates on how to handle that, namely how to cut costs while providing adequate care. There’s currently a shortage of 50,000 nurses and the nurses that are working say they’re overworked and underpaid. French citizens all get a carte vitale, a green card that proves they are in the system which has cut down substantially on the amount of paperwork. France expects to digitize that in 2025. Here’s a basic overview of how the French health care system (called the Sécurité Sociale, or the Sécu) works… 
A few notes… -No one tells the doctor what care you can and can’t have. The Assurance Maladie doesn’t say whether you can have a procedure or not; your doctor decides. Coverage does vary by procedure and some things are considered more elective than others. Most dental care isn’t covered, or well-covered, by the health care system. And experimental treatments and drugs sometimes fall outside of the coverage. -There are three different levels of doctors in France; Sector 1, 2 and 3. Sector 1 doctors are doctors who are conventioné (conventional), who adhere to the set (base) rates of the French health care system. For example, a standard doctor’s visit is currently €25 ($27). The system will reimburse the doctor for 65% of that and you (the patient) will be responsible for the rest. A Sector 2 doctor charges what they’d like, called honoraires libres (differing rates). So she or he may charge, say, €40 or €80 for an appointment, and the system will reimburse them the same amount as if they were Sector 1, which would be the same 65%, and you’d be responsible for the rest. Sector 3 doctors (who are often sought-after specialists) charge what they’d like—in Paris, a specialist may be €150—and the reimbursement rate is low. But there are talented specialists who work in the public hospitals and I recently had one who was Sector 1 conventioné. It may take longer to get an appointment with one that’s Sector 2 or 3. Interestingly, after my procedure, he told me he’d trained in Seattle and Southern California. -In order to pay the difference in what the French health care system covers, and the patient is supposed to cover, people in France buy private mutuelle insurance coverage, which pays the gap. Mutuelles are big business in France and they offer tiered services, depending on how much you want your monthly payments to be and what you want covered. Fun fact: Few people have nice things to say about their mutuelle in France and many resent paying for it as it’s part of the capitalisme of health care. One of my doctor’s said that no media outlets will do exposés on them because they spend so much on advertising. The differences in monthly fees can depend on how much you’re reimbursed to whether you’ll get a private room if you’re hospitalized. Payments range between €35-€150 per month. People of limited means can apply for a complémentaire santé solidaire to get it covered. -There are medical centers in France that are groups of doctors who operate as conventioné where the doctors are salaried and the costs fall into the Sector 1 category. At some of them you can get a same-day appointment or walk in, but at others, especially sought-after ones that specialize in dermatology (it’s very hard to find a dermatologist nowadays that’s accepting new patients), it can be weeks or months to get an appointment.
-Many visitors, especially from the U.S., are shocked (and delighted) when they go to a doctor or hospital in France and come out with a bill that’s only €35 or €80. The reason the bill is so low is that medical providers don’t have a mechanism to charge people fully for the actual cost of treatment. They are changing based on the what the French health care system charges (see above), which depends on French residents and citizens making contributions (i.e.; paying into it). It’s like an HMO health insurance co-pay in America; you’re making payments into the private insurance and that co-pay amount doesn’t reflect the actual price of the service. -France is facing a loss of doctors, in addition to nurses. If you live in a secondary city (not a big city, like Paris, Marseilles, or Rennes), there are a lot less of them, especially specialists. And if you live in the countryside, there are even less. My doctor told me many young people aren’t going into medecine since the pay is low. Starting salary is around €55,000/year in France whereas in the U.S. it’s $112,000. (The cost of living in France, however, is 30-37% less in France than it is in the U.S.) However some doctors want to continue to work within the public part of the French health care system, such as working at a public hospital, because the system has paid for their eduction and they want to remain a part of it.
-Pharmacists have a big role in French health care and almost every street in Paris seems to have a pharmacist on it. In France pharmacists are given a lot more leeway in France than they are in the U.S. While they can’t write prescriptions, they can diagnose you and carry out first-aid procedures as well as administer vaccines. People have close relationships with their pharmacists in France and it’s well-worth getting to know one in your neighborhood as they can give you valuable advice, including recommending health care providers in the neighborhood. In France, there are far fewer over-the-counter medications, such as cortizone and antibiotic creams, that either require a prescription or aren’t allowed to be sold anywhere except at pharmacies. There’s a national obsession with Paracétamol (acetaminophen) which is only available in pharmacists. They tried to pass a law to change that so it could be sold elsewhere, but the pharmacists when on strike to protest, and won. -Health care in France is not free. Employers pay social charges for each person they employ. If you’re self-employed, you are responsible for paying those charges. The rate varies depending on what kind of business you are in. It’s extremely confusing and very few people fully understand the intricate system. If you have a critical, long-term illness, you’ll may be able to get a special card that allows you to bypass all the paperwork and you won’t pay any co-pays or charges for healthcare. -If you have an emergency in France or in Europe, you can dial 112 (European emergency number) For medical and ambulance service, dial 15 For the pompiers (firemen) who respond to accident calls and are highly competent, and work with medical authorities, dial 18 If you don’t speak French, when contacting a health care provider, ask if they have an English-speaking person on staff if you need one, especially if it’s an emergency. (Some will not automatically switch to English if you’re trying to speak French, even if they speak English, to be polite. So don’t be afraid to ask.) Many medical providers either speak some English or work with someone who does.
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