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ANTADIR, Paris, France
Correspondence to: Olivier Roque d’Orbcastel, MD, Director, Antadir, 66 boulevard Saint-Michel, 75006 Paris, France; e-mail: antadir{at}antadir.com
To the Editor:
We are flattered by the article1 and the editorial2 on the French system of homecare. It is nice to know that our system has been noticed and recognized. However, things change continuously, and the world changes around us. Your article describes the system up to the year 2000, and since then things have changed. ANTADIR is facing challenges related to rising health costs in France and structural changes in the health service industry that have forced regional associations to make choices of direction.
Attempts to simplify reimbursement procedures and to reduce costs have led to a weakening of the Observatory as in-depth data are more difficult to accumulate. Doctors "in the field" find it difficult to see the usefulness of centralized data. Thus we have tended to publish more subset analyses of the Observatory data.345
The enhancement of regional services as you describe requires political vision and clear definition of requirements. Thus ANTADIR has developed its activity as a purchasing agency and as an assessor of technology as described on our website: ANTADIR.com. Expansion has occurred in other homecare areas such as perfusion, nutrition and insulin pump therapy. However the academic base moves more slowly than the commercial arena, and we find ourselves with healthy competition from the private homecare sector. We wonder how a very liberal economy, such as that found in the US, would cope with our nonprofit system?
We worry that France may be deconstructing the integration of the components of homecare that you vaunt, but we are heartened by a government commitment to the creation of integrating groups by supporting the creation of thematic unions (reseau de soins). For the moment, these mechanisms are bureaucratically complex and time consuming and do not promote national cooperation with a centralizing force such as ANTADIR.
We remain optimistic that our system will evolve while conserving such important tools as the Observatory. Nonprofit associations rely heavily on voluntary input; thus, we need committed volunteers like Dominique Robert, who recognize the benefits of quality and research. Budget restrictions and the demand for immediate value for money have made such pioneering more difficult today.
References
Chicago, IL
Correspondence to: Allen I. Goldberg, MD, Master FCCP, 1018 West Diversey Pkwy, No. 2, Chicago, IL 60614-1317; e-mail: agoldberg1988{at}kellogg.northwestern.edu
To the Editor:
All nations with a commitment to treating the increasing numbers of patients and families with chronic health conditions face growing economic restraints. A French law in 1901 authorized the formation of not-for-profit associations to serve the public good in ways that could be best done by, for, and in "a community." For half a century, French associations dedicated to the treatment of chronic respiratory insufficiency have proven their worth for patients and their families who require long-term mechanical ventilation.12345 Over time, the associations evolved to serve the needs of patients with other respiratory conditions and expanded services for additional long-term health conditions. There has been awareness for nearly a decade that these not-for-profit associations are being challenged by competition from for-profit organizations, which benefit from laws and regulations put in place to serve the comprehensive health and social needs of their target populations.
A strong cultural tradition in France encouraged the establishment and development of associations as the best way to meet societal needs. As an American, I have been privileged to follow with great admiration the "French system" of associations, which is focused on the following aspects of long-term care:
Health-care and social service funding should require outcome evidence to compare the not-for-profit and commercial approaches. The French national and regional associations have a medical/social model that works. They face an opportunity to work together to obtain the needed evidence of their worth. This would benefit greatly the patients in France and others around the world who require long-term care.
References
University of Maryland, Baltimore County, Baltimore, MD
Correspondence to: Mary Stuart, ScD, Chair, Department of Anthropology and Sociology, UMBC, 345ACIV-B, 1000 Hilltop Circle, Baltimore, MD 21250; e-mail: stuart{at}umbc.edu
To the Editor:
We thank Dr. d’Orbcastel for his update on the evolution of the French system of home care for patients with respiratory insufficiency. He reflected on the key role that Dominique Robert played in the initiation and development of the French system, and commented that, "such pioneering is more difficult today with budget restrictions and immediate value for money being demanded." How our societies will support and encourage innovation as we seek cost-effective systems that will increase the quality of life for people with chronic disabilities remains a fundamental question for the future. The interactions between publicly financed and privately financed medical care organizations and the academic enterprise are complex, and, to our knowledge, have not been thoroughly worked out in any industrialized nation. While private enterprise has the potential to encourage innovation and to develop new and more cost-effective paradigms for the delivery of care, there is also the very real potential that privately financed medical systems will seek to "cream" the less complex and less severely afflicted patients. Thus, the public sector is at risk for being left with the care of only the patients with the most costly conditions. In addition, the private market is limited as a mechanism for promoting innovations because of the low profit potential, which can be a problem with technology that is designed for small, highly specialized markets of disabled consumers, who are more likely to be unemployed or living on low fixed incomes when compared to the general public.
In this context, we have found that a central database like the ANTADIR Observatory offers policy makers and program managers a valuable tool in the cost-effective management of care for people with chronic diseases. There is a saying drawn from business experience in the United States: "If you can’t measure it, you can’t manage it." Given the value of your database as a management tool, perhaps financial incentives can be offered to the doctors "in the field" to encourage them to provide the data. This type of approach has proved to be beneficial in the United States, where it is recognized that one of the fundamental conditions for an "efficient marketplace" is good data.
We wish you the very best as you rise to the challenges of changing conditions.
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