Strategic Intelligence Monitor on Personal Health Systems

Transcription

1 Strategic Intelligence Monitor on Personal Health Systems Country Report France IPTS IS Unit

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3 TABLE OF CONTENTS 1 THE FRENCH HEALTHCARE SYSTEM BEST IN THE WORLD HEALTHCARE COVERAGE IN FRANCE ORGANISATIONAL STRUCTURE AND MANAGEMENT: POLICY LEVEL ORGANISATIONAL STRUCTURE AND MANAGEMENT: SERVICE PROVISION LEVEL HEALTHCARE EXPENDITURE AND FINANCING INNOVATION IN HEALTH AND SOCIAL CARE MANAGEMENT OF CHRONIC CONDITIONS IN FRANCE PHS AND RMT MARKET: FRENCH STAKEHOLDER INTERVIEWS PHS & RMT MARKET SITUATION AND ANTICIPATED GROWTH AVAILABILITY OF MARKET DATA: SCATTERED AND SCARCE FACTORS INFLUENCING THE MARKET DRIVERS AND BARRIERS Market Drivers Market Barriers RMT IN SOCIAL CARE CONTEXT PATIENT EMPOWERMENT VISION OR REALITY? CONCLUSION AND SUMMARY APPENDIX - RMT / PHS RELATED PROJECTS THAT WERE IDENTIFIED DURING THE INTERVIEW PROCESS IN FRANCE

4 1 The French Healthcare System Best in the World In the year 2000, the World Health Organization (WHO) chose the French healthcare system as the best in the world. Reasons behind the decision were France s universal coverage, responsive healthcare providers, patient and provider freedoms, patient satisfaction, and the health and longevity of the country's population. 1 Although the WHO no longer produces healthcare system rankings, due to methodological problems, France's healthcare system is considered to be among the top in the world. Despite prior success, France too is facing challenges adding pressure to the sustainability of the current system. On a national scale questions are being asked concerning the ageing population, the geographical distribution of available care, the attractiveness of the medical profession and new technologies 2. Although being highly rated, the French healthcare system is expensive to sustain. In light of demographic changes the pressure for changes even in the French healthcare system is already present. Table 1 shows some of the key figures describing the current situation and development of the French healthcare system. The French health care system is a mixed system combining elements of various organizational models and lies between the Beveridge and Bismarck models. It is a publicly funded system characterized by freedom of choice and unrestricted access for patients and freedom of practice for professionals. As a system the French model is complex and pluralistic in its management. This mixed system of organization reflects a balance between different values, such as equity, freedom and efficiency, but it also generates structural difficulties which provide the impetus for health care reforms. Reforms have been numerous concerning areas like extending financing and access to universal care. There have also been attempts to reduce the freedom of choice, although the effects of these have been weak Healthcare Coverage in France Healthcare coverage in France is universal. All residents are entitled to publicly-financed health care. Couverture Maladie Universelle (CMU) was introduced in 2000 which meant the state would cover those residents not eligible for coverage by the public health insurance scheme (0.4% of the population). 1 The World Health Report, Contribution of the French Mandatory Health Insurance Scheme to the European Commission s Green Paper on the European Workforce for Health, The French Health care system:liberal Universalism, 4

5 Table 1. French healthcare system in key figures. French Healthcare System Development in Key Figures Demographic references Total population - Thousands of persons Population: 65 and over - % total population 13,9 % 12,9 % 14,1 % 15,2 % 16,1 % 16,4 % 16,4 % Life expectancy, Females at birth - Years 78,4 79,4 80,9 81,9 82,8 83,7 84,4 Life expectancy, Males at birth - Years 70,2 71,3 72,8 73,8 75,3 76,7 7750,0 % Healthcare expenditure & financing Total expenditure on health (% GDP) 7,0 % 8,0 % 8,4 % 10,4 % 10,1 % 11,1 % 11,0 % Public expenditure on health (% of total expenditure) 80,1 % 78,5 % 76,6 % 79,7 % 79,4 % 79,3 % 79,0 % Total expendit. on health - /capita, US$ 2000 PPP $1 264 $1 518 $1 813 $2 330 $2 542 $2 941 $3 010 Healthcare resources Registered physicians - Density /1000 pop. 2,48 3,04 3,45 3,72 4,02 4,12 na Practising nurses - Density /1000 pop. (HC) 4,63 5,32 5,43 5,94 6,73 7,69 7,73 Medical graduates - / population 16,60 15,40 9,40 8,00 6,70 5,60 na Total hospital beds - /1 000 population 11,10 10,50 9,70 8,9 8,1 7,5 7,1 Healthcare Utilization Average LOS: in-patient care - Days 21,20 18,10 15,10 14,1 13,2 13,4 13,2 All procedures(in-p.+day) - /1 000 population na na na na na na na Doctors' consultations - Number /capita 4,20 5,20 5,90 6,4 6,9 6,6 6,3 Social Protection Old age - Public, % GDP 7,6 % 8,6 % 9,2 % 10,6 % 10,5 % 10,9 % na Coverage: Total, % of total population 99,1 % 99,2 % 99,4 % 99,4 % 99,9 % 99,9 % 99,9 % Coverage: Public, Total health care - % of total population 99,1 % 99,2 % 99,4 % 99,4 % 99,9 % 99,9 % 99,9 % Source: OECD Health data,

6 The state also finances health services for illegal residents (AME). The public health insurance scheme covers hospital care, ambulatory care and prescription drugs. It also provides minimal coverage of outpatient eye and dental care. 4 Cost-sharing is widely applied to publicly-financed health services and drugs and takes three forms: co-insurance, co-payments, and extra billing. The cost sharing rates will vary depending on factors like the type of care, the type of patient, the effectiveness of the prescription drug or whether or not patients comply with the recently-implemented gatekeeping system. For example patients suffering from chronic conditions are exempt from cost sharing. Reimbursement by the publicly-financed health insurance scheme is based on a reference price. Doctors and dentists may charge above this reference price based on their level of professional experience. The difference between the reference price and the extra billed amount must be paid by the patient and may or may not be covered by complementary private health insurance. 4 Complementary private health insurance covers statutory cost sharing (the share of health care costs not reimbursed by the health insurance scheme). Most people also obtain complementary private coverage through their employer. Complementary private health insurance covers over 92% of the population. In 2005 out-of-pocket payments and private health insurance accounted for 7.4% and 12.8% of total health expenditure respectively Organisational Structure and Management: Policy Level Health policy and regulation of the health care system is divided between the state, the statutory health insurance funds and to a lesser extent local communities. Public health policy and practice in France are difficult to describe because they involve numerous actors and sources of finance. In addition, there is a real discrepancy between policy documents that allocate roles and responsibilities to various bodies (often local authorities) and actual practice, which is determined to a large extent by self-employed doctors, hospitals and other institutions. This is particularly evident in the area of individual prevention of ill health. This problem is related to the historic separation between health care on one hand (the responsibility of the health insurance funds) and prevention and public health on the other (the responsibility of the state). 7 The implementation of France s health policy is the responsibility of the central government. It encompasses a range of plans meant to protect and improve the population s health, by means of both preventative and curative care. The French Ministry of Health strives to control the regulation of health care expenditures, on the basis of the overall framework established annually by parliament in a dedicated budgetary Act. This is designed primarily to orientate and drive the actions to be taken by the health insurance funds. The Ministry of Health has many responsibilities and tasks. It drafts bills on health and ensures that the laws passed by parliament are applied. The Ministry is responsible for dividing the budgeted expenditures between different sectors and between the different regions in France. It also decides on the number of hospital beds and the type and amount of equipment as well as approves the agreements signed between the health insurance funds and the unions of privately practising 4 The French Health Care System,

7 health care professionals. The Ministry of Health also sets the prices of drugs and defines priority areas for national programmes. 5 The statutory health insurance system consists of three main health insurance schemes which are the general scheme, the agricultural scheme and the scheme for non-agricultural selfemployed people. Each of the three major health insurance schemes has a national health insurance fund and local structures corresponding to the degree of geographical distribution involved. The health insurance schemes are under the supervision of the Social Security Directorate of the Ministry of Social Security. Since 1996, they have carried out their function as managers of the statutory health insurance system within the framework of an agreement on targets and management drawn up with the state for a minimum period of three years. The national funds of the three main health insurance schemes enter into this agreement with the Ministry of Health and the annual appendix to the agreement sets out the total target budget for the remuneration of self-employed health care professionals. The three national funds are responsible for managing this budget, known as the allocated expenditure target. Within this framework they negotiate with the relevant professionals to ensure that these expenditure targets are met. In practice, however, this system was only implemented for a year, in The regional hospital agencies (ARH) are responsible for hospital planning (for both public and private hospitals), financial allocation to public hospitals and adjustment of tariffs for private for-profit hospitals (within the framework of national agreements). They bring together, at the regional level, the health services of the state and health insurance funds, which previously shared management of this sector. ARH directors are appointed by the Council of Ministers and are directly responsible to the Minister of Health. 7 The regional unions of the health insurance funds (URCAMs) bring together the three main health insurance schemes at the regional level. They coordinate the work of the funds and give impetus to a regional policy of risk management. In relation to the ARHs, whose role is operational, their function is more to influence and stimulate, and they do not have authority over the regional and local funds. 7 Regional unions of self-employed doctors (URMLs) carry out functions in the following areas: analyses and studies regarding the functioning of the health care system, private medical practice, epidemiology and the evaluation of health care needs; coordination with other health care professionals; providing information and training for doctors and patients. These unions engage in dialogue with the ARHs and the URCAMs. 7 In principle, the regional level is now structured so that it has the capacity to take strategic directions for the health care system and to manage it coherently. The 2001 Social Security Funding Act reinforced this trend by providing ARHs with a mandate to authorize experiments to set up networks of health care providers. 7 5 WP5 - National reports of EHR implementation, France, Healthcare Systems in Transition: France, Healthcare Systems in Transition: France,

8 1.3 Organisational Structure and Management: Service Provision Level Primary and secondary health care that does not require hospitalization is delivered by selfemployed doctors, dentists and medical auxiliaries working in their own practices, and to a lesser extent, salaried staff in hospitals and health centres. Around 1000 health centres, usually run by local authorities or mutual insurance associations, along with some organizations offering free treatment to disadvantaged groups, are also active, albeit more marginally, in the delivery of outpatient care. Almost all self-employed health care professionals practice within the framework of the national agreements signed by the professionals representatives and the health insurance funds which determines the fee-forservice basis. Outpatient care is largely provided by self-employed doctors (both generalists and specialists) in their own practices. Most of these doctors work alone. Only 38% of doctors are involved in group practices, and these are usually general practitioners aiming to achieve a better allocation of time or specialists in fields that require extensive technical capacity. Officebased consultations form the basis of general practitioners work, but home visits represent about 25% of their work. In one year a general practitioner sees, on average, 1400 different patients and carries out around 4800 consultations and visits. Outpatient care provided by self-employed specialists is more difficult to describe because it varies greatly by specialization. Consultations account for 55% of specialists work, with the rest consisting of diagnostic and treatment procedures. Doctors benefit from total freedom to choose where they wish to practice, and geographical disparities in the distribution of doctors have existed for a long time. The North of France has a lower supply of doctors than the southern regions and Paris, which are more attractive to doctors. At sub-regional levels, inequalities are even more significant between urban and rural areas, as well as between the centre and the periphery in urban areas. The 2004 health financing reform law introduced a voluntary gate keeping system for adults (aged 16 years and over) known as "médecin traitant". There are strong financial incentives to encourage gate keeping. The cost per visit is slightly higher for specialists ( 23; $33) than for GPs ( 22; $32) and is based on negotiation between the government, the public insurance scheme and the medical unions. Depending on the total duration of their medical studies, physicians may charge above this level. There is no limit to what physicians may charge, but medical associations recommend tact in determining fee levels. Secondary and tertiary inpatient care is provided by the French hospital system which in 2005 consisted of about 2,850 public and private institutions. The range of medical specialities provided varies between hospitals. Public hospitals (around 990 in 2005) account for a third of all hospitals and two thirds of the inpatient beds. There are three levels of public hospital (regional most of which are also university hospitals, general and local hospitals). The local hospitals provide non-specialised healthcare. Most health care services delivered by regional and general hospitals consist of specialised care, although they are meant to provide non-specialised health care for the people residing in the local area as well. Private hospitals (around 1,870 in 2005) fall into two categories: non-profit or for-profit. Nonprofit hospitals (around 800) are owned by non-profit private trusts, mutual benefit (complementary) health insurance funds, foundations, or by congregational trusts. They account for less than a third of hospitals and 15% of inpatient beds. The range of services 8

9 provided by non-profit hospitals varies widely. Private for-profit hospitals (around 1,050) account for more than one third of all hospitals in France and 20% of all inpatient beds. They tend to specialize in certain areas. Two-thirds of hospital beds are in government-owned or not-for-profit hospitals. The remainder are in private for-profit clinics. All university hospitals are public. Hospital physicians in public or not-for-profit facilities are salaried. Since 1968, hospital physicians have been permitted to see private patients in public hospitals, an anachronism originally intended to attract the most prestigious doctors to public hospitals, and one that has survived countless attempts to abolish it. From 2008, it was intended that all hospitals and clinics would be reimbursed via the DRG (diagnosis related groups)-like prospective payment system (the original DRG scheme was only to be fully implemented by 2012). Public and notfor-profit hospitals benefit from additional non activity-based grants to compensate them for research and teaching (up to an additional 13% of the budget) and for providing emergency services and organ harvesting and transplantation (on average an additional 10-11% of a hospital s budget). A number of policies exist to encourage methods of providing care that are alternatives to complete hospitalization, such as day care surgery or treating patients in their homes (known as hospitalization at home in France). In each case, the extension of capacity for patients treated at home must be authorized. Authorization is granted in return for closing down acute beds, with a theoretical exchange rate of one place for two beds, which may be adjusted at the regional level to take account of existing bed numbers. Hospitalization at home (HH) has existed in France for about forty years, even though the statutes that define its precise functions as an alternative to hospitalization are comparatively recent. 18 HH consists of providing continuous and necessary coordinated medical and paramedical treatment in the patient s home. It can be organized structurally under a hospital service or a non-profit association and calls on the services of health care professionals who may be employed by hospitals or self-employed practitioners. Within each structure, a coordinator (a doctor) ensures the satisfactory medical functioning of the whole service, but nurse-managers coordinate individual treatment. However, In spite of the incentives available, the development of alternatives to complete hospitalization remains limited by international standards. On a service provision level a weakness of the French healthcare system is the lack of coordination and continuity of care provided by often isolated professionals. This can lead to over-prescription and waste, but also inadequate care paths and insufficient quality. Even if doctors advise their patients correctly, they are not in a position to monitor the whole process of care. The lack of coordination is not limited to self-employed professionals: the interface between hospital care and ambulatory care on one hand, and between health care and social care on the other hand (especially for disabled or elderly people), is also often a problem. Two experiments have been set up to try and address this situation: the referring doctor and provider networks. On the social care side a potentially prosperous area for remote patient monitoring services is home care. Home care in France is delivered by self-employed professionals or by specialized home care services, but it is likely that supply is insufficient to meet need. Furthermore, although care in the community is considered a priority, it suffers from poor coordination 9

10 between health services financed by the health insurance funds and social services managed by local government. 1.4 Healthcare Expenditure and Financing The public health insurance scheme is financed by employer and employee payroll taxes (43%); a national income tax (contribution sociale generalisée; 33%) created in 1990 to broaden the revenue base for social security; revenue from taxes levied on tobacco and alcohol (8%); state subsidies (2%); and transfers from other branches of social security (8%). CMU is mainly financed by the state through an earmarked tax on tobacco and through a 2.5% tax on the revenue of complementary private health insurers. There is no ceiling on employer (12.8%) and employee (0.75%) contributions, which are collected by a national social security agency. Public expenditure accounted for 79% of total expenditure on health in Cost control is a key issue in the French health system, as the health insurance scheme has faced large deficits for the last 20 years. More recently the deficit has fallen, from billion per year in 2003 ($14-17 billion) to an expected 6 billion in 2007 ($8.6 billion). The decrease in deficit may be attributed to a reduction in the number of acute hospital beds, limits on the number of drugs reimbursed, an increase in generic prescribing and the use of over the counter drugs, the introduction of a voluntary gate keeping system in primary care, protocols for the management of chronic conditions, new co-payments for prescription drugs and the fact that ambulance transport will not be reimbursable by complementary private health insurance. On the other hand, recent news shows a different trend with the French government reporting an expected deficit of 23,5 billion in 2009 and 30,6 billion in This only proves that in the past as well as in the expected near future, France s healthcare spending has been and continues to be generous compared to many other OECD countries and significant overspending with respect to the global cap (ONDAM) set by Parliament is typical. Main reasons for this include the 100% coverage regime for long-term illness, the fact that private doctors do not respect medical guidelines and the difficult distribution of hospital capacities. 9 Some of the key figures related to French healthcare expenditure and its development are presented in Table Innovation in health and social care Overall, the French healthcare system is faced with the necessity to reform if it wishes to maintain the quality of services without having to further increase expenditure. In France, during the past decade, there has been increasing awareness of the importance of Health ICT and ehealth, which has led to setting of a series of laws in the field of public health and social security. 10 France has also launched experiments involving on-call facilities using general practitioners based in hospitals, call centres staffed by physicians, and arrangements with physicians specializing in the provision of all out-of-hours services in return for higher fees The French Health care system:liberal Universalism 10 ehealth priorities and strategies Ettelt et al

11 However, the national strategy seems to be more focused on optimization and reengineering of the existing healthcare system and infrastructure, than on new innovations. Moreover, there is a broad consensus among different stakeholders that the Internet and ICT in general need to be utilised as tools in the re-organisation of healthcare in France, but the pace of reform of the system has been quite slow, also implying the health professionals willingness to adopt the public policy directives has not been sufficient. 12 Most general practitioners and specialists (except for those working in hospitals) practice privately in their offices outside hospitals, which means that their involvement in making the reform happen will require incentives and possibly changes in the legal framework. The French health system is claimed to be institutionally complex, which easily leads to tensions between the state, the health insurance funds and providers. There is the need to improve their cooperation by clarifying the responsibilities of these key actors. The uptake of online health services by French citizens has been claimed to be affected by the low penetration and usage of the Internet, and by the fact that the French tend to have a high degree of confidence towards the traditional role of the family doctors. Today, however, the internet use in France is rapidly increasing, together with search of health related information online. The SESAM-Vitale system, which aims at using ICT to simplify and accelerate exchanges among health care providers, and between health care professionals and the endusers, will in the near future give users of the Vitale card secured access to new services (e.g. Personal Medical File), which provides opportunities also for further development of new types of services. Several outstanding regional applications and platforms, in the fields of telematics, telehealth, and telemedicine, are already in use in different regions. The DMP project (Dossier Médical Personnel 13 ), aims to present a real opportunity to organize the cooperation and the articulation at the national level between the local and regional projects and the national one, by building on accepted reference practices for security and interoperability based on international standards. By now, the development of DMP has occurred at the regional level (e.g. The DPPR in the region of Rhône-Alpes), where the implementation is already in progress. 12 ehealth in Europe The French personal medical record 11

12 Table 2. Expenditure on health in France. French Healthcare System Development in Key Figures: Expenditure on Health Expenditure on health Total expendit. on health - Million US$, 2000 PPP $ $ $ $ $ $ $ Total expendit. on health - /capita, US$ 2000 PPP $1 735 $1 952 $2 091 $2 383 $2 671 $2 840 $2 936 Total expenditure on health (% GDP) 7,0 % 8,0 % 8,4 % 10,4 % 10,1 % 11,1 % 11,0 % Public expenditure on health (% of total expenditure) 80,1 % 78,5 % 76,6 % 79,7 % 79,4 % 79,3 % 79,0 % Private expenditure on health (% of total expenditure) 19,9 % 21,5 % 23,4 % 20,3 % 20,6 % 20,7 % 21,0 % Expenditure on personal health Tot. exp. personal health - % total exp. on health 93,0 % 93,3 % 93,5 % 87,3 % 87,6 % 88,1 % 88,3 % Tot. exp. in-patient care - % total exp. on health 49,4 % 47,6 % 44,3 % 40,9 % 38,3 % 37,0 % 37,0 % Tot.exp. out-patient care - % total exp. on health 21,1 % 22,2 % 23,7 % 18,3 % 18,0 % 17,4 % 17,5 % Tot. exp. home hlth care - % total exp. on health 0,2 % 0,2 % 0,3 % 2,3 % 2,1 % 2,5 % 2,7 % Total exp. medical goods - % total exp. on health 18,5 % 18,9 % 20,1 % 17,9 % 20,2 % 20,8 % 20,6 % Expenditure by financing agent / scheme Government., excl. soc.sec. - % total exp. on health 4,3 % 3,6 % 2,3 % 4,6 % 4,5 % 4,9 % 5,2 % Social security schemes - % total exp. on health 75,8 % 75,0 % 74,3 % 75,1 % 74,9 % 74,3 % 73,8 % Out-of-pocket payments - % total exp. on health 12,8 % 14,4 % 11,4 % 7,6 % 7,1 % 6,8 % 6,8 % Private insurance - % total exp. on health 5,7 % 5,9 % 11,0 % 11,9 % 12,7 % 13,2 % 13,4 % Source: OECD Health data,

13 Coverage decisions are the most important lever for introduction and generalization of new technologies in France. A four step procedure to introduce new technologies in France includes: 1) Marketing authorization (drugs) CE marking (medical devices), 2) Assessment of expected and actual clinical benefits (HAS), 3) Price negotiation and 4) Coverage decision 14. The French National Authority for Health (HAS) is tasked to assess procedures related to pharmaceuticals, medical devices and health care and to produce national guidelines. The key role of HAS is in health technology assessment for new medical devices. 15 HAS mission is to put quality at the heart of professional practice and of the healthcare system, which drives them to establish public health priorities. The role of the HAS in relation to chronic diseases is explained in more detail later. As an example of a regional organisation, ASTRHA (Association pour la Telemedicine en Rhone-Alpes) has the goal to put together health care providers, researchers, patients associations as well as economic and institutional partners to create an arena for cooperation. At national level, a new agency called CNR, has been established under the Ministry of Economy and Industry but it also works in cooperation with the Ministry of Health, with the aim to push the market and to help it evolve and become more mature. Instead of focusing on the care provided in the hospital, it focuses on care provided at home. CNR gathers a variety of related stakeholders including technology and service providers, health service providers, policy makers and patient organizations representing the citizens as well as the payers, i.e. the insurance companies. CNR has just started and will be announced officially by the Ministry of Economy and Industry in December of CNR began with 8 organizations in 4 regions with each region being represented by both supply and demand groups. Currently there is very little information available on CNR and its role in the innovation processes concerning RMT will have to be analyzed at a later phase. An organization called L'Hospitalisation A Domicile (HAD) 16 has recently issued specifications for what they would ideally need from IT to help patients to be monitored from home, however, this is also still in very early stages of development. These specifications include sophisticated systems which enable controlling vital functions from a distance (e.g. heart beat, blood pressure). Progress is foreseen in stages starting with only basic information, to keep it simple and realistic and avoid being too ambitious. The plans range over a years period, and HAD is currently designing the route towards this goal. 2 Management of chronic conditions in France In France, the management of chronic disease has until very recently been dependent mainly on the initiative of health professionals, who chose whether or not to follow guidelines and coordinate their activities to provide comprehensive treatment because a failure to do so did not lead to financial penalties for patients who anyhow benefited from 100% coverage, regardless of the quality and quantity of prescriptions. There have been concerns about a lack of coordination and continuity of care in the French healthcare system, both in the ambulatory Free English translation: hospitalisation at home 13

14 sector and on the interface between ambulatory and hospital care, which have led to a series of changes 17. In France, the two major approaches to chronic disease management include the health network approach and the long-term disease (ALD) procedure. The changes aiming to improve the coordination, continuity and interdisciplinarity of health care provision of care started in 1996, with the introduction of mechanisms stimulating experiments with different provider networks at the local level, which eventually formalized as health networks (Réseaux de Santé) in the 2002 Patients Rights and Quality of Care Act 18 with a particular focus on selected population groups, disorders or activities. In 2004, chronic disease management and patients quality of life were identified as one of the top five priorities for the French public health policy. The 2004 Public Health Law defined a series of health targets for (chronic) diseases together with some risk factors while the 2004 Health Insurance Law reformed the traditional long-term disease ALD (affections de longue durée) procedure, which exempts patients with long-term conditions from copayments if their care adheres to evidence-based guidelines. These were followed by the 2007 national Public Health Plan on the quality of life of people with chronic illness, which led to a promotion of structured disease management experiments. However, these initiatives have been argued to lack an integrative vision, with no clearly defined objectives, procedures for implementation, not to mention incentives and sanctions 19. Table 3 summarizes the key figures related to selected chronic diseases in France. The French National Authority for Health (HAS) mentioned earlier a relatively new public scientific body - was created under the 2004 Health Insurance Reform Act, which reformed the regulation and financing of health care in France. The HAS is an independent body, tasked to assess procedures related to pharmaceuticals, medical devices and health care and to produce national guidelines. The HAS plays a key role in the development of guidelines for treatment of chronic diseases and defining eligibility criteria for inclusion in the ALD system. The HAS is also responsible for production of updated operational protocols and recommendations, which are expected to be integrated with three other important changes under way to optimize chronic disease management and allow better coordination between health professionals in France. These include (1) the development of an electronic personal medical record, (2) increased patient responsibility for health care (self-management), and (3) a mandatory role for GPs as key coordinators of individualized health care. The 2004 Health Insurance Reform Act was set out to improve quality of care and to develop patient education, in order to improve self-management. The Act also introduced a gatekeeping function aiming to reinforce the role of primary care physicians in coordinating care and to optimize care in a cost-efficient way. However, there are doubts about the overall impact of this measure, since more than 90% of patients already consult the same physician on a regular basis, and patients are still facing difficulties in navigating through the system and benefiting from coordinated delivery of services. In France, primary care has been traditionally provided by doctors, typically in single-handed practices with few support staff. Due to the legal framework in France, the development and 17 Sandier et al Frossard et al Nolte et al

15 implementation of new roles and competencies has turned out to be challenging, which makes substitution and delegation of tasks by doctors difficult and does not encourage educational approaches to self-management support. While job descriptions of health care professions are legally defined, redefining roles and delegating tasks to non-medical personnel requires changes in the corresponding law. Transferring competencies from one group of professionals to another has been done on a pilot basis, for example, to transfer responsibility for diabetes education and counseling from endocrinologists to dieticians. Also payment systems often hinder the delegation of tasks from doctors to other health professionals. In France, the payment of providers on a fee-for-service basis does not encourage improved coordination between physicians and nurses. Moreover, there have been some concerns whether it would be necessary to provide a specific training for nurses to take over new tasks as well as the current lack of both nurses and physicians in rural areas. Between 2000 and 2005, the social health insurance (SHI) invested approximately 650 million into health networks. In addition to this, the SHI spent 240 million for primary care physicians to coordinate the care of patients with chronic diseases, corresponding to a payment of 40 per patient suffering with an ALD. In addition to a budget for infrastructure and operating costs, the SHI provides incentives to providers, involving set fees for individual yearly assessment, education and dietary counseling by nurses and dieticians. Non-financial incentives are implicit in the networks definition and include preferential access to specialists with otherwise long waiting lists, access to continuing medical education and training programs, and newsletters for patients containing dietary and other practical information. There are also negative incentives for providers, for example time commitment, fear of losing patients to other specialists and weakening of professional identity. 15

16 Table 3. Key figures of chronic conditions in France. French Healthcare System Development in Key Figures: Chronic Conditions and Life-Style Causes of mortality Diseases circulatory sys. - Deaths / pop. 282,6 252,9 195,4 172,6 157,1 133 na Diabetes mellitus - Deaths / pop. 10,0 9,3 7,7 6,9 11,5 10,9 na Diseases respiratory sys. - Deaths / pop. 46,2 44,6 41,2 39,3 33,7 30,6 na Length of stay Diseases circulatory sys. - Days na na na na 7,40 7,10 6,90 Heart failure - Days na na na na 10,20 10,00 9,70 Angina pectoris - Days na na na na 5,20 4,50 4,40 Hypertensive diseases - Days na na na na 9,5 7,7 7,1 Diabetes Mellitus - Days na na na na 8,0 7,5 7,2 Obstructive pulmonary dis - Days na na na na 9,3 9,0 9,0 Disharges Diseases circulatory sys. - / population na na na na Heart failure - / population na na na na Angina pectoris - / population na na na na Hypertensive diseases - / population na na na na Diabetes mellitus - / population na na na na Obstructive pulmonary dis - / population na na na na Lifestyle Alcohol consumption - Liters /capita (15+) 19,50 17,30 16,00 15,10 14,0 12,7 na Tobacco consumption - % of pop. daily smokers 30,00 na 30,00 29,00 27,00 na na Overweight or obese pop. - % of total population na na 29,70 33,40 36,2 na na Source: OECD Health data,

17 In 2005, the Ministry of Health s General Inspectorate for Social Affairs (IGAS) group carried out a comparative analysis of disease management models in the United States, Germany and the United Kingdom to benchmark their respective experiences, which led to an integration of some components of the Chronic Care Model (CCM), developed by Wagner, into the French system. However, many characteristics of the French health care system tend to hinder the adoption of the entire model. Among the major constraints, is the continued lack of coordination between medical and social services due to the division of budgets and employees between the regions, the State and the SHI. In 2006 the SHI and unions representing medical doctors signed a special agreement regarding annual follow-up of diabetic patients clinical pathways, which can be seen as a first step towards a true disease management process, involving both the SHI and referral doctors. As described above, a wide range of measures has been introduced to enhance care for patients with chronic disease(s) in the French system. However, there has not been enough effort to synthesize these approaches into an overarching policy with defined objectives, implementation rules, incentives and enforcement mechanisms, jointly agreed or negotiated by key stakeholders. Currently, mechanisms tend to be broadly doctor oriented and lack the vital patient involvement. The Ministry of Health s IGAS report suggested two options to meet patients needs better: via the primary care team, which comprises one or more physicians working closely and systematically with other health professionals to define precisely and to target common health outcomes for patients or via specific interventions delivered by specially trained staff within disease management programs as a complementary service to the usual care delivered by GPs. These programs would be managed through call centers that would provide information, patient education and coaching, contributing to coordination of care and monitoring. Out of these two, DMPs seem to be the preferred option, especially in the short term because working conditions for doctors in France are not well suited to chronic disease management due to above mentioned barriers. Also, there continues to be strong cultural and professional reluctance to an intermediate type of chronic disease manager and to novel methods of monitoring health and delivering care. However, at the same time, some characteristics of the French health system are likely to promote the development and implementation of DMPs, including quality enhancement and cost reductions in hospital care. Although, outpatient services and hospital information systems are not integrated, public insurers have an access to information, which helps identify patients with chronic disease and stratify them according to their level of risk, based on currently observed pathways. In the future, this will be supported by the national uniform electronic medical record system. Also, the 2007 national Public Health Plan on Quality of Life for the Chronically Ill (PQVMC) promotes piloting and financing of DMPs, especially for diabetes and heart failure, and in particular the development of education for diabetic patients, involving coherently and simultaneously health professionals, patients and the SHI system. 3 PHS and RMT Market: French Stakeholder Interviews As in the case of Germany, Sweden and the UK (see next sections), France s healthcare system could benefit from large-scale implementation of personal health systems and remote patient monitoring. In the face of similar challenges concerning the ageing population, the 17

18 increasing prevalence of chronic diseases, constant cost pressures and the uneven geographical distribution of medical professionals, there will be a clear need for new kinds of services that address these challenges in different ways than currently is possible. Although market estimates on the future of RMT are scarce, and potentially unreliable, they all indicate positive trends in terms of growth of the industry. Frost & Sullivan has estimated that the total revenues for the French RMT market will amount 32.0 million USD in 2009 with an estimated compounded average growth rate of 10,7% from 2007 to An umbrella organisation in France, the Association of Teleassistance (AFRATA), has estimated potential market growth on the same lines as F&S with expected growth of about 10% over the next three years 21. Based on our interview findings with a selected group of French stakeholders, we can state that there is no real RMT market yet in France. Stakeholders believe RMT has significant potential to become a major part of healthcare delivery in the future, but before this happens there are significant barriers that will have to be overcome. These barriers are built deep into the current structures and attitudes of the healthcare system and are difficult to overcome without a common vision to which all stakeholders are committed to in the long-run. 3.1 PHS & RMT Market Situation and Anticipated Growth The French RMT market is currently at a formative stage with pilot studies, mostly on a local or regional level, making up most of the market. Knowledge of RMT has increased which has led to a shift in interest from purely technological gadgets to the actual services that these gadgets could enable. The shift in interest has not however, turned into an increase in actual demand. Success stories are limited or non-existent, while RMT service providers struggle to see their pilot studies develop into sustainable business solutions. While technology has advanced, the market has not been able to mature during this time. Acknowledging the market s poor ability to implement RMT services in practice, general expectations of RMT market growth have been toned down. Although stakeholders still believe in the potential of RMT, beliefs in rapid growth of the market have been replaced by a perhaps a more realistic view on things RMT market growth will happen, but it will do so gradually. Estimates on when the RMT market in France will mature were scarce and estimates on the current size of the market were not given. The current level of action taken to facilitate RMT market growth on a political level was seen as insufficient. With the state playing such a central role in the French healthcare system, some felt it would take at least until the next governmental election until the process of change enabling RMT market growth would begin. On the other hand, others saw regional initiatives and projects as the key in driving market growth. Some also felt that projects on a national level in the past have been very unsuccessful making it a better strategy to start off regionally and locally. Overall, views on RMT market growth and diffusion of services were based on a mixture of both top-down and bottom-up approaches. Before the organization of healthcare services changes, realizing potential RMT growth will be difficult. 20 European Remote Patient Monitoring Markets, Frost & Sullivan

19 Although the RMT market is still fragmented partnering among different actors and stakeholders is becoming more common. The importance of partnering has arisen from the fact that penetrating the RMT market is not something that can be done alone and building value chains with partners will result in better performance. Although RMT success stories were not mentioned, it was believed that achieving success will eventually require the contribution of RMT technology providers, healthcare service providers, communications, users, intermediate users as well as political support. Partnering is also being enhanced by umbrella organizations like ASIP (perhaps CNR in the future) and partnering among research institutes has also progressed. Besides partnering, acquisitions of both small companies and intellectual property rights to RMT devices were also being attained by larger companies. This is a clear sign of business entities positioning themselves favorably when market growth finally happens. 3.2 Availability of Market data: Scattered and Scarce Definitions in the field of RMT seem to have different meanings to different people. Probably due to the low amount of activity and actual business concerning RMT, the terminology related to it is fuzzy. This makes finding and categorizing data more difficult. Regardless of fuzzy concepts and boundaries in the scope of RMT, availability of RMT data overall is scarce. The availability of actual market data is even harder to come by. The slowly emerging French RMT market is very fragmented, which obviously leads to fragmented market data as well. The case is no different whether one looks at qualitative or quantitative data. One of the tasks of the new agency CNR will be to collect available data on RMT. If this data is then made publicly available through one sight, it will be a significant step forward in France. The main sources of market data noted were the internet, publicly available reports, word of mouth and academic papers. The availability of information including academic research was seen as insufficient. A problem concerning academic papers and their availability is the time consuming research process followed by an often even more time consuming publishing process. The amount of RMT related academic papers in review is currently unknown. Certain private initiatives noted were lists of devices and technologies concerning RMT are available. Also from a scientific point of view information can be found from a technical and professional society called Société Française des Technologies pour l Autonomie et de Gérontechnologie (SFTAG). French stakeholders saw a wide variety of information that they thought would be helpful in facilitating RMT market growth. The most noted area was evidence-based facts and proof of outcomes. The finding was similar to that of Germany and Sweden. It seems the market is not gaining the support it needs because stakeholders with decision making power concerning RMT deployment are not convinced yet. The potential cost savings and health benefits of RMT are often talked about on a general level as if they were scientifically proven facts, but in light of available information this is clearly not the case. Action to facilitate RMT market growth will require further evidence. Besides evidence-based facts French stakeholders call for actual guidelines on how RMT services can be implemented into day-to-day practice. Information concerning reimbursement possibilities and successful business models would also be of use. More information was felt needed on these areas as well as on patients such as where results had actually been achieved and where RMT efforts should be prioritized in the beginning (the real potential population). Also the need for information on potential partners in the field of RMT in different countries was felt to be of use when searching for partners to collaborate with. Other noted facts were the need for clear definitions of RMT related terminology and actual market research data on 19

20 how many elderly people and people with chronic diseases would actually be interested in using RMT services. Overall, the need for realistic quantitative data was emphasized, as numbers are the only way to make politicians believe in RMT. 3.3 Factors influencing the Market Drivers and Barriers In light of the RMT market situation in France RMT market barriers outweigh the RMT market drivers. Interviewed stakeholders recognized a strong need for major changes in healthcare service delivery, but did not see it happening currently. RMT is something that will happen, but it also seems to be something that doesn t have to happen immediately. As long as this remains the case, overcoming the current barriers will be difficult Market Drivers The French stakeholders mentioned several key drivers that could potentially facilitate RMT market growth. The fact that the French population is growing older, the prevalence of chronic diseases is increasing and that there is a lack of doctors in rural areas were all mentioned as key market drivers. Interviewed stakeholders felt that realizing RMT market growth will require actions taken both on a political level (top-down diffusion) and actions taken by citizens, industry and service providers (bottom-up diffusion). In order to achieve this several stakeholder groups will have to take an active role as change agents. Interviewees emphasized that realizing the market can not be done without collaboration among the various stakeholders. Most commonly mentioned driving stakeholder groups were the government and politicians, medical professionals (mainly doctors) and the citizens themselves. The French government and Ministry of Health were seen as key stakeholders in driving the RMT market in France. It was believed they had the power to create the rules of the game concerning RMT. Only after these rules had been set would other stakeholders dare to take a more active role. This according to some interviewees was already beginning to happen, although others emphasized that there is a long road from when discussions and interest on a political level are turned into action. Politicians on all federal, regional and local level were seen as key stakeholders in facilitating RMT market growth, due to the fact that politicians often have the power to facilitate in getting the financing for RMT projects. These projects are needed as showcases to drive the market forward. Citizens attitudes and demand towards RMT were also mentioned as a potential key driver in realizing market growth. One interviewee felt this was perhaps the only driver in the current healthcare system, because the system itself has not actively pursued finding a place for RMT. Citizens as a driving force can change the market in two ways. Firstly, adoption of RMT will increase when services and devices are sold directly to the patients (citizens) who are willing to pay for them out of their pocket. This scenario however, seems unlikely as in most cases patients are not willing to pay. Secondly, citizens could drive the market forward by demanding RMT services from the system and putting pressure on those responsible for future health policy. Both scenarios would require patient education and spreading knowledge of RMT. This is closely related to patient empowerment. In order to empower a patient they have to have the will to be empowered. To achieve this patients and citizens will need education. Also doctors were mentioned as a potential driving force. They have an important role in both educating patients and also utilizing RMT in their day-to-day routines. If doctors see the benefits of RMT and are provided with the proper incentives adoption rates of RMT will 20