This is France — Health Care: An Evolving System

Nr 17 – February-March 2009
This is France — Health Care: An Evolving
System
It has been said for some time that the French system of Health and Social Security was
among the best in Europe. Unfortunately, that is changing; the quality of health care is
diminishing, not because of the competence or devotion of the medical personnel, which
remain generally remarkable, but because of the decreasing budget allocations, for example,
for maintaining hospitals, many of which have become quite dilapidated, or for ensuring
adequate staffing. The emergency rooms are always totally overflowing with patients and
have an increasingly difficult time just meeting daily requests for services. And the fact that
president Sarkozy has appointed Roselyne Bachelot, who is perhaps the least serious of any
minister in the government, the most controversial at least for the whole of the political
spectrum, as the ministry of health is a sign of his lack of interest in maintaining the
excellence of the health care system.
Reforms aimed at reducing costs
Whereas the Social Security system has been criticized for more than twenty years because of
the constantly increasing deficits – the French usually call it “the hole of the Sécu”. The
government has taken measures to try and reduce the deficit. While some reforms were
necessary, especially those aimed at eliminating frequent abuse and fraud, others have been
fairly detrimental to the previous excellent level of coverage; some procedures and
prescription drugs are now reimbursed at a much lower percentage. And it is not always
certain that all the proposed reforms have actually resulted in reducing costs, such as the
controversial, especially with doctors themselves, requirement that patients first see their
médecin traitant before consulting a specialist (see the article elsewhere in this feature).
The French are turning to alternative techniques
Many French people are therefore increasingly disillusioned by their health care system, and
more and more French are turning to alternative approaches to medicine, also known as “soft”
medicine. It is easy to see the correlation Not so very long ago, all the alternative techniques,
such as acupuncture, homeotherapy, osteopathy, etc., had a very bad reputation with most
people. Today, many of the good pharmacies encourage their clients to take homeopathic
medications and many more practitioners of acupuncture and osteopathy are establishing
practices in France, and their waiting rooms are always full. A sign than the French have
understood that traditional medicine cannot do everything for them. The same is true of their
approach to feeding themselves where there is an exponential increase in demand for organic
food. The French also seem to be moving more and more away from the idea of a welfare
system that is hyper protective and the sole source of care and sustenance to the point where
people sometimes forget the most important truth: our bodies belong to us, and only we can
understand them, listen to them, and take the best possible care of them.
Santé en France : un système en pleine
mutation
On a longtemps pu dire que le système français de santé, et de Sécurité sociale, était l’un des
meilleurs d’Europe. Malheureusement, c’est en train de changer ; le niveau de qualité des
soins de santé est en baisse, non pas à cause de la compétence ou du dévouement du personnel
médical, qui demeurent généralement remarquables, mais de l’insuffisance des budgets
consacrés, par exemple, à l’entretien des hôpitaux, dont beaucoup deviennent vétustes, ou au
renforcement du personnel. Les services d’urgences sont toujours complètement débordés et
ont beaucoup de mal à faire face aux demandes quotidiennes. Et le fait que le président
Sarkozy ait confié le ministère de la Santé à Roselyne Bachelot, la personne peut-être la
moins sérieuse du gouvernement, la plus controversée en tout cas par l’ensemble de la classe
politique, est un signe du peu d’intérêt qu’il accorde au sujet.
Quant à la Sécurité sociale, elle est décriée depuis plus de vingt ans à cause de l’augmentation
constante de son taux de déficit, couramment appelé par les Français “le trou de la Sécu”, au
point que le gouvernement Sarkozy se soit attelé à réduire ce déficit. Si certaines réformes
étaient nécessaires, surtout pour éviter les abus et fraudes, fréquents, d’autres sont au
détriment du très bon niveau de prise en charge, de sorte que certains traitements, soins ou
médicaments sont beaucoup moins bien remboursés. Et il n’est pas certain que toutes les
réformes entreprises aident réellement à réduire les coûts, dont celle, très critiquée par les
médecins eux-mêmes, de l’obligation de prendre un “médecin traitant” et d’aller le voir avant
la moindre visite chez un spécialiste, comme nous l’expliquons dans un article de ce dossier.
Bon nombre de Français sont donc de plus en plus désenchantés par leur système de santé.
Mais, et il n’est pas impossible de voir un lien entre les deux, ils sont aussi de plus en plus
nombreux à se tourner vers les médecines alternatives, aussi appelées médecines douces. Il y
a encore très peu de temps, toutes les techniques alternatives, telles l’acupuncture,
l’homéothermie, l’ostéopathie, etc., avaient une très mauvaise réputation auprès du grand
public. Aujourd’hui beaucoup de bonnes pharmacies encouragent la prise de médicaments
homéopathiques, et les acupuncteurs et ostéopathes sont bien plus nombreux à s’établir – et
leurs cabinets ne désemplissent pas. Un signe que les Français, et il en est de même pour les
habitudes alimentaires et l’attraction récente et croissante pour le bio, ont compris que la
médecine traditionnelle ne peut pas tout. Et aussi qu’ils perdent un peu cette mentalité
d’“assisté” qu’encourageait un système devenu parfois hyper protecteur au point qu’ils
venaient à oublier la chose la plus importante : notre corps nous appartient, et il appartient
avant tout à nous-mêmes de le comprendre, de l’écouter, et d’en prendre le meilleur soin
possible.
Annick Stevenson
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Le médecin traitant
The principle:
Since January 2005, every person living in France who is covered by the French Social
Security (which means that the expatriates who have settled in France are also concerned)
must have designated his/her own médecin traitant: a generalist who is their main doctor,
their main referent. And each time they feel the need to consult a doctor for any medical
reason, they first have to go see their médecin traitant, who will then be able to send them, if
needed, to a specialist. If the patient goes to the specialist without a referral from le médecin
traitant, the specialist’s fees will not be fully reimbursed. This doesn’t apply, though, to the
following specialists: gynaecologist (gynécologue), stomatologist (stomatologue),
ophthalmologist (ophtalmologue), dentist (dentiste), psychiatrist (psychiatre) for patients
between 16 and 25 years old, and paediatricians (pédiatre) for children.
This measure had been taken with the pretext that it will help reduce the deficit of the Social
Security, and also that it would allow a better follow-up of the patients. However, this is not
really the case, as it often obliges each patient to visit two doctors for only one medical
problem, and then to get two reimbursements from the Social Security instead of one. And
the doctors themselves, who are overloaded with work, complain that it is a loss of time. As
they are always so busy, they don’t even examine the patient who comes for his signature
before visiting his usual specialist, which means that there is no follow-up at all by the main
doctor of his patient’s condition.
The new rules as of February 2009:
Four years after the start of this reform, some 15% of the holders of a Social Security number
have not yet signed up for their own médecin traitant. In view of this state of facts, the
government has just decided to increase the penalties for those are still refuse to do so. As of
February 2, 2009, patients who still consult directly their specialist will see their
reimbursements diminish from 50% to 30%.
It is, therefore, wise to do it now, even if you will hear your doctor himself still complaining
about it! You just need to chose any generalist convenient to you, visit him once, telling him
that you need a médecin traitant, fill out the form he will give you, and mail it to your local
Social Security office. And each time you need to visit a specialist who is not on the list
above, you have to go see this doctor before, as useless and time-consuming as it may appear.
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Scenario: At the Doctor’s
Marie-France Lelièvre est malade depuis
deux jours. Elle se décide de se rendre,
sans rendez-vous, chez son médecin
traitant, puisque c’est le jour de sa
consultation.
Marie-France Lelièvre has been feeling
sick for the last two days. She decides to
go see her usual doctor, as it is the day he
sees his patients without an appointment.
Le docteur : Bonjour, Madame Lelièvre,
qu’est-ce qui vous amène ?
Marie-France : Bonjour, docteur, oh, je ne
vais pas bien du tout ! J’ai mal partout depuis
deux jours, j’ai des courbatures dans le dos,
j’ai mal à la gorge, j’ai de la fièvre…
Le docteur : Combien ?
Marie-France : J’avais 40 hier soir et 38,8
ce matin.
Le docteur : Avez-vous votre carte Vitale ?
Marie-France : Bien sûr. La voici.
Le docteur : Bien, on va voir ça.
Déshabillez-vous.
Marie-France : Est-ce que je dois tout
enlever ?
Le docteur : Non, seulement le pull. Je vais
vous examiner au stéthoscope. Voilà.
Allongez-vous. Est-ce que vous toussez ?
Marie-France : Oui, un peu.
Le docteur : Je vois ça. Vous avez les
bronches un peu prises. Respirez
profondément… Encore… Ne respirez plus.
Essayez de tousser un peu. Bon, maintenant
je vais prendre votre tension. Ne bougez
plus…
Marie-France : Est-ce que c’est la grippe ?
Le docteur : Eh bien oui, il n’y a aucun
doute. Il y a une mauvaise épidémie cette
année. Et elle est très contagieuse.
Marie-France : Donc mon mari risque de
l’attraper ?
Le docteur : Il y a de bonnes chances.
Marie-France : Est-ce que vous allez me
donner des antibiotiques ?
Le docteur : Ah non ! Vous n’avez pas
entendu la pub “Les antibiotiques, c’est pas
automatique” ? La grippe c’est un virus, et
les antibiotiques ne peuvent rien faire pour
les virus, seulement pour les bactéries.
Marie-France : Oh la la ! Mais je peux rien
prendre ?
The doctor: Good morning, Madame, what
brings you here?
Marie-France: Good morning, doctor.
Well, I don’t feel well at all! For the last two
days I have had pain everywhere, my back is
stiff, I have a sore throat, I have a fever…
The doctor: How high?
Marie-France: It was 40 last night, and 38.8
this morning.
The doctor: Do you have your carte Vitale?
Marie-France: Yes, here it is.
The doctor: Well, we’ll just take a look at
that. Get undressed.
Marie-France: Do I have to take everything
off?
The doctor: No, only the sweater. I am
going to examine you with the stethoscope.
Have you been coughing?
Marie-France: Yes, a little.
The doctor: I can see that. Your bronchial
passages are a little congested. Breathe
deeply… Again… Don’t breathe at all…
Now, I am going to take your blood pressure.
Don’t move…
Marie-France: Is it the flu?
The doctor: Well yes, there is no doubt
about that. There is a very bad epidemic this
year. And it is very contagious.
Marie-France: So my husband may get it
too?
The doctor: There is a good chance.
Marie-France: Are you going to give me
antibiotics?
The doctor: Oh no! You haven’t heard the
ad: “Antibiotics are not automatic?” The flu
is a virus, and antibiotics cannot do anything
for a virus, only for bacteria.
Marie-France: Wow! So I can’t take
anything?
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Le docteur : Si, je vais vous donner quelque
chose pour faire tomber la fièvre et calmer
les douleurs. Mais vous savez, le meilleur
remède c’est de vous reposer complètement,
rester couchée, et prendre votre mal en
patience ! Bon, vous pouvez vous rhabiller.
Marie-France : Bon, eh bien merci docteur.
Je vous dois combien ?
Le docteur : 22 euros… Merci. Et voilà
votre ordonnance et votre carte Vitale ! Au
revoir, Madame Lelièvre.
Marie-France : Au revoir, docteur.
The doctor: Yes, I am going to give you
something to bring the fever down, and
relieve the pain. But you know, the best
remedy is total rest, to stay in bed, and to be
patient! OK, you can get dressed.
Marie-France: Well, OK, thank you doctor.
How much do I owe you?
The doctor: 22 euros... Thank you. And
here is your prescription and your carte
Vitale! Good bye, Madame.
Marie-France: Good bye, doctor.
Gynaecologist: An Endangered Species
Some twenty years ago, the wide majority of French women had the habit of seeing their
gynaecologist at least once a year for most of their lives, once every two years after the age of
menopause, and they would have never thought of replacing him/her by a generalist. French
women quite naturally turned to their gynaecologist (affectionately simply called a gynéco)
who would council them about birth control choices, deal with the pains and problems
incurred by women, such as sexual problems or difficulties with their companion. And most
importantly, they were an important element in a woman’s prenatal care during a pregnancy.
Only the gynaecologists who are qualified as obstetricians (gynécologue-obstétricien) can
actually do a delivery (accouchement), especially in case of complications – as most
deliveries are done by midwifes (sage-femmes) – but the gynéco (formally called gynécologue
medical) played a very active role from detecting a new pregnancy right up until the actual
birth.
French women liked their gynéco
The gynéco had become even more than that, and for many women he/she was the medical
person she trusted the most, the one to whom she used to tell the most private secrets of her
life, her advisor almost. The most famous French female cartoonist, Claire Bretécher, gives
more space to the gynéco than to the shrink as the permanent councillor of her very popular
characters.
All this has changed a lot. Today, there is only one gynaecologist left for every 3,700 women.
After the termination in 1984 of the specific training to become a medical gynaecologist,
more and more new doctors have chosen to become obstetricians or surgeons, who don’t have
the same time to devote to their patients as the traditional gynéco and whose prices are higher.
In view of the expressed need, the French Government adopted a new reform in 2006,
creating again a specific training of medical gynaecologist. However, it is very late, and the
numbers of graduates in the field every year is so small that the overall number of
gynaecologists is diminishing drastically. While they number about 1,900 today, it is
expected that there will be fewer than 500 or 600 in 2020.
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The obvious result of this situation is that more and more women have difficulties finding an
available gynéco close to their home, and chose to be treated by their generalist, who are
cheaper and more accessible than an obstetrician. But if some of the GPs are excellent at it,
while others are not; and even if they do their best, they will certainly not be as generous with
their time and availability as the professional gynaecologists. Many women regret very much
loosing this ability to have a face-to-face exchange with someone of trust and
professionalism.
A.S.
Basic Words and Expressions
Un accident vasculaire cérébral = a stroke
Une allergie = an allergy
Les antibiotiques = antibiotics
Une attaque cardiaque = to have a heart attack
Une bactérie = bacteria
Un bobo = a little pain, scratch or bump (a word used by small children)
La carte Vitale = a credit-card sized card with a microchip verifying that you have medical
coverage through the system. Can be used in pharmacy for direct payment for prescription
drugs.
La clinique = the clinic (private).
Consulter = to examine, to go see, consult
Un contrôle = a check up
Des courbatures = stiff muscles. J’ai des courbatures) = I ache (I’m stiff) all over
Le docteur = the doctor
La doctoresse = the doctor (female)
Une douleur = a pain
Etre enrhumé = to have a cold
Une entorse = a sprain
Un évanouissement = a blackout, fainting spell
La fièvre = a fever
Une fracture = a fracture
Une grippe = a flu
L’homéopathie = an homeopathic medicine
L’hôpital = the hospital
L’hospitalisation = hospitalization
Une indigestion = an indigestion
Un infarctus = a heart attack
Un(e) infirmier(ère) = a nurse
Une intraveineuse = an intravenous injection
Mal (j’ai mal) = a pain
Un mal au dos (j’ai (un) mal au dos) = My back hurts
Un mal à la gorge = a sore throat
Un mal à la tête = a headache
Un mal au ventre = a stomach ache
Un malade = a sick person
Etre malade = to be sick
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Le médecin = the doctor.
Le médecin traitant = the doctor who normally treats you (you may choose your own
médecin traitant, but if you see a specialiste without being referred by your médecin traitant,
you won’t be fully reimbursed for the specialist by the sécu)
Les médicaments génériques = generic medication/drugs
Une migraine = a migraine
La mutuelle = a complimentary health insurance that covers what the sécu doesn’t. Highly
advisable.
Une ordonnance = a prescription
Une piqûre = a jab, a shot
Une prise de sang = a blood test
Une radio = an x-ray
Un rhume = a cold
Your Neighbourhood Pharmacy
In France, you can easily recognise the pharmacies by their bright blinking green crosses.
Only pharmacies are permitted to sell over-the-counter medications and prescription drugs.
The chemists in France are highly-qualified, as they hold a diploma requiring six years of
university studies.
A very good customer attitude
Going to the pharmacy is usually a pleasant experience as the chemists are for the most part
friendly and have a very good customer service attitude - they will usually help you with a
smile. Even if they are not a substitute for a doctor, they can be a good place to start. Do not
be afraid to ask for advice or describe your symptoms, they will give you their focused
attention in order to point you in the right direction. They can also give general health and
lifestyle advice, such as telling you to try to stop smoking or to watch your diet, etc. They
also have details of all the health related services in the area, and you can even go to them
with a basket filled with mushrooms, and they can tell you if they are edible or not!!
In case you get sick in the middle of the night, you can always go the pharmacie de garde.
Each pharmacy in a given city takes turns staying open 24 hours a day. Every pharmacy in the
city will usually put up a post on their door telling where the pharmacie de garde is. If you
are a enrolled in the French social security system and hold a carte Vitale, you will have only
a small part (or sometimes nothing) to pay for the medication prescribed by a doctor.
Some pharmacies offer a wide range of homeopathic products and are specialised in that field.
If you wish to find a natural remedy to your problem, you should go to a pharmaciehoméopathie.
Homeopathic solutions are proposed
Homéopathie falls in the category of la médecine douce – They will propose homeopathic
solutions for such things as digestive problems, skin problems, a sore throat, etc…It’s an
alternative to taking prescription drugs in order to avoid any side effects. Most pharmacies
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sell some homeopathic products, but it’s much better to go to a pharmacy specialised in it as
you will receive some experienced advice.
There are also herboristeries
Some pharmacies also offer a section in remedies involving natural herbs and are called
herboristeries. They are easily recognized by the tins of herbal blends that cover their walls.
In herboristeries, you can find infusions for almost any situation as well as essential oils,
dietary supplements, some organic cosmetics, etc. You can also benefit from their advice.
Céline Anthonioz
Some Useful Expressions for Your Next Visit to the
Pharmacy
J’aimerais vous demander un conseil = I would like to ask you for some advice?
J’ai de la fièvre/j’ai de la température = I have a fever/a temperature
J’ai un problème de digestion = I have a digestion problem
La tête me tourne = I feel dizzy
Est-ce que vous avez quelque chose pour calmer la douleur ? = do you have something to
ease the pain?
J’ai été piqué par une bête ! Je peux vous montrer la morsure ? = I was bitten by an
insect! I can show you the bite?
Je ne dors pas bien, pouvez-vous me suggérer une tisane ? = I’m not sleeping well, can
you suggest an herbal tea?
Je ne me sens pas bien ! = I don’t feel well
J’ai des crampes à l’estomac = I have stomach cramps
Est-ce que je devrais aller chez le docteur ? = should I go see a doctor?
Est-ce que c’est remboursé par la sécu ? = Is it reimbursed by social security?
J’ai une toux ; pouvez-vous me donner un sirop ? = I have a cough; can you give me a
cough syrup?
Je voudrais essayer de l’homéopathie = I would like to try homeopathy
Quelles sont les effets secondaires possibles ? = what are the possible side effects?
Je n’ai pas d’ordonnance = I don’t have a prescription
J’ai une toux, un mal de gorge et un mal de tête, j’ai besoin de quelque chose d’efficace !
= I have a cough, a soar throat and a headache, I need something effective!
Est-ce que ce shampoing est bio ? = is this shampoo organic?
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The Most Common Practitioners of
Alternative Medicine
Le rebouteux
If you go to a small village in France, the locals will be very attached to their family doctors
and many are also convinced that their village rebouteux (healer) is the person to go to when
they have any problems related to their skeletal system. In other words, they are bone or joint
manipulators; they have their place in the society and are part of the village traditions. They
don’t have a diploma and most have no formal training; they don’t have an official status and
therefore are not recognised by the Ministry of Health but are tolerated and are taxed just like
family doctors. They are mostly found in the countryside of France. The rebouteux have a
long term history throughout the different generations and are well respected, even more than
some mind-body practitioners such as yoga instructors. In recent years, some yoga instructors
were ‘driven’ out of some villages located in Haute Savoie, France, because they were
suspected of being some kind of religious sect.
L’ostéopathe ou le kiné
The more recognised practitioners in the alternative medicine field are the ostéophathes,
known as a physiotherapist in English (close to the chiropractor’s role in the US) or the
kinésathérapeute known as a physical therapist. An increasing number of practitioners call
themselves a kiné-ostéopathe. An ostéopathe médecin has a medical degree and can prescribe
medication and the patient can be reimbursed for the doctor’s part the visit. However, the
ostéopathe non médecin is not in a legal position to prescribe anything and the patient has to
pay out of their own pocket. There are only a few chiropractors in France.
Usually the ostéopathe works with the mechanics of the spinal column and on the particular
painful areas, whereas the kiné, translated as physical therapist, focuses primarily on those
individuals whose potential or actual impairment is related to musculoskeletal,
neuromusculoske-letal, cardiopulmonary, and skin systems. It also focuses on methods of
evaluating the functions of these systems and on the selection and application of appropriate
therapeutic interventions to alleviate pain; to maintain, improve, or restore function; and to
prevent dysfunction. For example, if your baby has some form of bronchitis, the family doctor
will most probably send your baby for a few sessions with the kiné to help eliminate the
mucus that has accumulated in the lungs. The family doctors work more and more with the
kinés or the osthéopathes.
Since stress has become more and more medically recognised as a source of potential medical
problems and dislocations to the skeletal system, doctors will often send the patient to the
alternative medicine practitioners.
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If you wish to be reimbursed for going to the kinés, make sure you ask for a prescription from
your normal family doctor (see comments on le médecin traitant elsewhere), otherwise you
will not be reimbursed!
C.A.
Useful to Know...
La carte Vitale
Every person who has medical coverage through the French Social Security System receives a
green carte Vitale, which is almost like a Health ID Card for each individual. All necessary
medical and insurance information is included on the chip embedded in the card, and in many
cases it makes it possible to avoid paying medical expenses up front. This is the case, for
example, when you go to a pharmacy with a prescription after a visit to the doctor: you just
have to pay the portion of the medicine which is not reimbursed by the Social Security. And
if you have a Mutuelle (see below), you may not have to pay anything. The carte Vitale is
also very useful in case of emergency as it contains your blood group and the details of your
Mutuelle.
The carte Vitale has to be regularly updated in a machine called a borne, that are located in
pharmacies.
A new version of the carte has recently been launched in the country. It will have an
expanded memory chip and be able to contain more information (contact information, medical
history and the name of your médecin traitant) – and will be less easily falsified. The first
recipients of the new card will be in Brittany and the Pays-de-la-Loire.
La Mutuelle
A Mutuelle is a complementary medical insurance (complémentaire santé), provided by a
non-profit organization (not to be confused with a private insurance), which is very advisable
to take out, all the more so now that the percentage of medical expenses that are not refunded
is growing. Its cost varies according to the coverage you choose, but it will certainly, at least,
pay 100% of most medical treatments, a percentage of dental care (that the Social Security
almost doesn’t reimburse at all), etc.
For very good coverage it should be enough to pay a monthly 100-120 € for a couple.
To find a Mutuelle is not easy, especially as there are so many. Here are two websites, in
French only, which compare some of them:
www.quellemutuelle.com
www.mutuelle.com
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Emergency Numbers
15: SAMU (Service d’aide médicale d’urgence)
The free and centralized number for medical emergencies for the entire country.
18: Les pompiers (firemen)
To call if you don’t get an immediate satisfying response from the SAMU.
3624: SOS Médecins
Only in a big or medium-size city, a network of about 1,000 doctors all over France, who will
come to your home as soon as they can, usually within a few hours. The service is available
seven days a week and at any hour of the day or night. Their record is impressive. Created in
1965, they handle 4 million calls everyday, and make more than 2 million house calls to
private homes every year. And in fact, they handle most of the calls to the SAMU requiring
urgent medical advice in urban and peri-urban areas. Their website, English version:
www.sosmedecins-france.fr/en
Pharmacie de garde
(Emergency pharmacy on duty)
There will always be a pharmacie de garde on weekends not too far from your home. Its
address is indicated on the front door of every pharmacy and is listed in the local newspaper.
A few websites giving health information for expatriates
French Entrée
www.frenchentree.com/fe-health
Expatica
www.expatica.com/fr/health_fitness/healthcare_list.html
Anglo Info
http://france.angloinfo.com/countries/france/healthinsure.asp
Understand France
www.understandfrance.org/Paris/Sick.html
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