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«Abstract The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis ...»

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International Study of Health Care Organization and

Financing for end-stage renal disease in France

Isabelle Durand-Zaleski1, Christian Combe2, Philippe Lang3

1. Department of Public Health, AP-HP, Henri Mondor Hospital, Paris, France

2. Université Bordeaux 2 Victor Segalen and Department of Nephrology, Centre Hospitalier Universitaire

de Bordeaux, Bordeaux, France

3. Department of Nephrology, AP-HP, Henri Mondor Hospital, Paris, France

Abstract

The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis stations. In 2003, the prevalence of ESRD in France was 0.087%. Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants. The annual expenditure per ESRD patient in 2003 was estimated at €40,975. Autodialysis, at €49,133 per patient per year, was much less expensive than dialyzing in-center at either a public or private facility (€111,006 and €75,125, respectively). Transplant activity in France has rapidly increased in recent years, reaching 22 donors per million population in 2005.

This paper is part of the International Study of Health Care Organization and Financing, which examines how the treatment of renal failure is paid for around the world. This study comprises 13 related papers published in a two-part special issue of the Inter- national Journal of Health Care Finance and Economics. The original published version of this paper (© Springer Science+ Business Media, LLC 2007) is available at www.springerlink.com.

The ISHCOF is a substudy of the Dialysis Outcomes and Practice Patterns Study (DOPPS). The ISHCOF is supported by the Arbor Research Collaborative for Health; the DOPPS is supported by research grants from Amgen and Kirin Pharma without restrictions on publications. Arbor Research thanks Springer for permission to reproduce this article.

Reference: Durand-Zaleski I, Combe C, Lang P. International study of health care organization and financing for end- stage renal disease in France. Int J Health Care Finance Econ 7(2-3):171-183, 2007.

Durand-Zaleski, Combe, & Lang, 2007 Page 2 of 14 Introduction In this brief study of the management of end-stage renal disease (ESRD) in France, we examine how the regulation, ownership, and financing of the health care system have created incentives that shape current practice. The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis beds/stations. The relative deficit in kidneytransplantation due to the scarcity of donors is being corrected by a recent increase in organ recovery.

The French health care system has been traditionally considered a Bismarckian system, providing health care coverage to salaried workers and families based on financing through social charges. The single public payer, Social Security, collects social charges from employers and employees to pay for hospitals, physicians, drugs, and devices via sickness funds. In the past, when only employed citizens had Social Security, this financing system was sufficient. Over time, however, coverage was extended to rural workers, nonsalaried professionals, and eventually the whole population. To finance this increased population, state funds were introduced in 2000. These income-tax-based funds now compose 50% of the total Social Security budget.

Public and private not-for-profit hospitals are financed by a diagnosis-related group (DRG) prospective payment system, which is being progressively implemented to replace the previous fixed-budget system. The same is true for private for-profit hospitals, which were previously financed on a per diem basis. Office-based physicians (both general practitioners and specialists) and physicians who practice in private hospitals are paid on a fee-for-service basis. The level of the fee is negotiated between the physicians’ unions and the Social Security Administration.

Physicians who have reached a certain academic level can claim, from their patients, payment above the negotiated fee. This additional payment may be reimbursed to the patient through supplemental, voluntary insurance.

Social Security is a national, single public insurance system that finances sickness, maternity, and family benefits as well as retirement pensions. It covers 100% of the population and roughly 75% of all medical expenditures. Private insurance companies reimburse the remaining 25% of health expenditures. Ninety percent of the population purchases private insurance with cofinancing from employers or with government vouchers (for low-income citizens). However, ESRD patients do not need private insurance because they are covered 100% by Social Security.

Medical unions represent roughly 10% of the total population of office-based fee-for-service physicians. Unions are traditionally separated by professional specialization and political affiliation. The following six unions represent general practitioners and specialists and negotiate with the Ministry of Health and Social Security: the Confédération des syndicats médicaux français, the Fédération des médecins de France, the Syndicat des médecins libéraux, the Union collégiale des chirurgiens et spécialistes français, Médecins Généralistes France (general practitioners only) and Alliance.





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practitioner or specialist) they choose, with no ceiling on the number of doctors seen or the frequency of visits. There may be a copayment, partly or fully covered by the supplemental insurance, depending on the doctor seen (but not on whether the doctor is a general practitioner or a specialist; general practitioners can also charge above the Social Security ceiling). An experiment is under way to create a system in which, as of 2006, every person chooses a “médecin traitant” to act as a gatekeeper. This is intended to prevent misuse of referral systems and reduce specialist consultations. On the doctor side, there is freedom of prescription for both drugs and tests. The exceptions are a limited number of drugs restricted to hospital use and the limitations imposed by medical regulatory references (i.e., practice guidelines now carry a financial liability in case of noncompliance) (Durand-Zaleski, Colin, & Blum-Boisgard, 1997).

The combination of freedom of choice with a high coverage of medical expenditures and a feefor-service payment for physicians in private practice typifies the French health care system and applies to the care of ESRD patients.

As far as patients are concerned, the out-of-pocket payment does not apply to a list of 32 chronic diseases for which the costs are entirely covered by Social Security; ESRD is part of this list.

This means that Social Security pays directly for all medical treatments and drugs for those patients. Social Security covers all treatments and fees at a predefined rate; additional services, such as private rooms in clinics and specialists’ fees above the standard rates, can be purchased by patients or reimbursed through private supplemental (commercial or noncommercial) insurance.

Methods

This paper is part of the International Study of Health Care Organization and Financing (ISHCOF), a substudy of the Dialysis Outcomes and Practice Patterns Study (DOPPS). The DOPPS is a multifaceted, multiyear international study of the variations in practice patterns and treatment of ESRD patients on hemodialysis and their impact on clinical and other outcomes.

ISHCOF aims to characterize economic structures and their impact on the delivery of dialysis care. The study is based primarily on one-time commissioned surveys (2004– 2005) and subsequent papers by authors from each of the 12 DOPPS countries. Details of the methods are described in Dor et al. (2007).

In general, the reported statistics and data are based on secondary data sources, including published articles, government documents, government Web sites, and local medical institutions such as the Bulletin Épidémiologique Hebdomadaire (the Weekly Epidemiological Report); the Direction de la Recherche des Études de l’Évaluation et des Statistiques (the Direction of Research in Evaluation and Statistics from the Ministry of Health); the Agence Technique de l’Information sur l’Hospitalisation, or ATIH (the Agency of Information on Hospitalization); and L’Assurance Maladie en Ligne (the French Social Security database). When possible, independent validation of the ISHCOF data was performed with external data sources such as national kidney failure registries, World Health Organization reports, the Organization for Economic Cooperation and Development (OECD) database, and published articles. All monetary estimates were provided in national currency units and converted to U.S. dollars with OECD purchasing power parities (PPP) from the year of each figure (OECD, 2006). Due to the small Durand-Zaleski, Combe, & Lang, 2007 Page 4 of 14 number of economic investigators and countries in this study, international comparisons reported here are informal and qualitative, unless otherwise noted.

Annual expenditures for each modality type were estimated from two main data sources: a cost report from the French Social Security Agency (CNAM, 2005) and the U.S. Renal Data System Annual Report (USRDS, 2005). In Table 1, the costs are shown for hemodialysis treatment in both public and private centers, as well as for autodialysis centers. Though transportation costs are shown in this table, they are not used in subsequent estimations in order to maintain consistency with measures from other countries participating in the ISHCOF. The hemodialysis estimates shown in Table 1 were weighted by the proportion of patients receiving each type of HD care to obtain an overall estimate of the annual cost per HD patient. Peritoneal dialysis was estimated at 41% of the annual cost of hemodialysis, as was found by the Social Security Agency’s report. In the United States, functioning renal transplant patients cost 24% as much as hemodialysis patients and that patients in the year of transplantation cost 620% as much as patients with a functioning graft (USRDS, 2005); Table 2 assumes that these percentages also apply in France. The final estimate of the annual expenditure per ESRD patient was obtained by weighting each modality’s cost by the proportion of French ESRD patients on that modality.

The gross epidemiology of kidney disease and provision of care in France

Data concerning the ESRD epidemiology in France have been scarce because of the absence of a national registry. An effort titled Réseau Épidémiologique et Information en Néphrologie (REIN) collects, as of the end of 2006, data from 18 of 22 regions in France and provides high-quality epidemiological information. The objectives of this registry are to estimate the incidence, prevalence, and mortality of kidney disease patients; to describe their treatment modalities; and to describe the demographic and other characteristics of the ESRD population. The information reported here is the best data available at this time (Couchoud et al., 2006).

In 2003, the prevalence of ESRD in France was 0.087% (Macron-Noguès et al., 2005a). Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants (Babeau & Trigano, 2004). Between 1997 and 2001, the incidence of ESRD increased 31% or at an average annual rate of 7% (AMELI, 2005). Most of this increase is attributed to the increased prevalence of type 2 diabetes in the French population; other hypotheses include a better reporting system and the increased willingness of physicians to refer frail and elderly patients to dialysis due to improvements in dialysis technologies and drugs.

The prevalence of kidney transplantation in 2004 was 0.038% (Jacquelinet, Savoye, Kessler, & Durand, 2005). Between 1997 and 2001, kidney transplant incidence increased 18% (Jacquelinet et al., 2005). The corresponding average annual percentage increase of 4.2% was one of the highest among ISHCOF countries (data not shown). But the rate of transplantation has continued to grow to nearly 6% per year since 2001 (Jacquelinet et al., 2005). This great increase is the result of a national policy to increase the donation rate from 15 to 20 donors per million inhabitants. The Ministry of Health has provided human resources and financial means to achieve this goal, mostly by increasing the number of coordinators to recover organs in hospitals Durand-Zaleski, Combe, & Lang, 2007 Page 5 of 14 and by launching a national donation campaign. In addition, the age limit for donors was increased to 70 years, resulting in an increased number of donors.

The age- and sex-standardized prevalence of ESRD is higher in the southern and the most north central regions of the country (Fig. 1) (Macron-Noguès et al., 2005b). Regional variations in transplantation have been described previously; they concern all types of organs and are related mostly to historical factors (early implementation of teams involved in organ recovery and transplantation) and differences in practice patterns (Macron-Noguès et al., 2005c; RoudotThoraval, Romano, Spaak, Houssin, & Durand-Zaleski, 2003).

Forty-six percent of France’s ESRD patients are treated at the 151 public dialysis facilities; the remaining 54% attend 130 private facilities. Figure 2 presents the share of the public and private sectors for hemodialysis, self dialysis, and home dialysis. Though 58 of these 130 private facilities are nonprofit, the majority (55%) are for-profit. The trend has been toward consolidation and private ownership of hemodialysis facilities; one single investor, Nephrocare (Fresenius), has a 30% market share of hemodialysis in France. Another large investor used to be Baxter, which sold its facilities to B-Braun Avitum in 2004. The development of these private for-profit facilities for inpatient dialysis is explained by their lower costs relative to a favorable reimbursement system (fee for service).



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