A new plan to improve chronic-disease management

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

In 2008 the National Sickness Fund piloted a chronic disease management program called ?Sophia? in order to improve coordination and quality of care for diabetic patients. In November 2010, the program was extended to further regions. It gives support to diabetic patients already diagnosed and identified through the sickness fund database. The interventions are tailored to suit the individual needs of patients and rely mainly on nurses working in call centres.

Purpose of health policy or idea

The objective of the program is to improve the quality and efficiency of care provided to diabetic patients by improving the follow up of patients, their therapeutic education and the coordination of care provided in ambulatory, hospital and long-term care settings.

Diabetes is the most frequent chronic illness in France, affecting about 2.5 million people, and representing 9 billion Euros per year for the public health insurance. Diabetes is classified as a long-term disease (ALD) in France, which means that all expenses related to its treatment are covered 100% by the public insurance. It can trigger many complications if not followed up properly. It is estimated that each year 12 000 foot amputations and one third of dialysis are due to the complications of diabetes.

The program, called Sophia, was piloted in 2008 in 10 departments with an objective of reaching 136 000 type I and type II diabetic patients (6% of all patients) treated by 6000 GPs. It is intended to act as an intermediary between patients and their generalists. Patients who are diagnosed with diabetes (and are on the ALD register) are contacted by the health insurance fund by mail and asked to join the program. In order to join, patients need to fill up a form and send it to the Health Insurance. There is no cost involved for patients. Once in the program, specialised nurses and/or health counsellors contact patients, by telephone and mail, to provide them with personalised information on how to manage their diabetes (dietary advise, prevention measures, etc.) and find the most appropriate solution in terms of where/how to get the right care, if necessary. The number of calls and type of information given depend on the health status of the patient and risk of complication.

In parallel, local insurance funds will have contacted the generalists who are following up these patients to explain them the objectives and functioning of the program. Generalists involved are paid 66 Euros per year/patient. However, there is nothing specific mentioned in terms of what GPs are supposed to do for Sophia.

Main points

Main objectives

The main objective is to improve the coordination, efficiency and quality of diabetic care. It is believed that self-management is essential to good diabetes care and patient education can reduce potential complications.

The health insurance fund also believes that investing in patient education can improve efficiency in the system.  

Type of incentives

Financial for GPs, since they are paid for each patient participating in the program. Non-financial for patients.

Groups affected

General practitioners, nurses, National Sickness Fund, patients.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

One major weakness of the French health system is the lack of coordination between health care providers, which is particularly problematic for patients with chronic diseases. 

In the past ten years, several reforms were introduced for encouraging new models of care delivery such as health networks. In 2006, the Ministry of Health commissioned an audit of these networks. The evaluation carried out by the Auditing Office of Social Affairs (IGAS, Inspection Général des Affaires Sociales), suggested that the policy of health care networks encouraging collaboration between health professionals has had little impact on improving chronic care management and coordination between office- and hospital-based physicians.

The report by IGAS also identified the disease management approaches in the US, mainly driven by insurance companies, and in the UK, where chronic patients are managed in group practices by nurses employed by the practice, as "more successful" examples. Given the highly fragmented nature of primary care organisation in France, with mainly fee-for-service based health professionals working in solo practice, the authors of the report expressed their doubts about the ability of professional organisations to endorse disease management in France.  

The National Health Insurance Fund is encouraged to take an active role in informing patients and directing them in the system, going beyond its traditional reimbursement function. 

In the National Plan for improving the quality of life of patients with chronic diseases (2007-2011), prepared by the Ministry of Health, investing in patient education was identified as a major priority.

Initiators of idea/main actors

• Providers

• Payers

• Patients, Consumers

Approach of idea

The approach of the idea is described as:
renewed: The idea is not original, other countries use call centres for providing information to patients. But it is new in France as this the first time the public health insurance fund is involved actively in health promotion and prevention.

Stakeholder positions

General practitioners and diabetes specialists are neutral to the program. While the diabetic patient association and federation of patient associations are very supportive of the initiative, they ask for more structured support for patients with better developed recommendations.

Actors and positions

Providers
GPs	very supportive		strongly opposed
Specialists	very supportive		strongly opposed
Payers
Social health insurance fund	very supportive		strongly opposed
Patients, Consumers
Patient associations	very supportive		strongly opposed

Actors and influence

Providers
GPs	very strong		none
Specialists	very strong		none
Payers
Social health insurance fund	very strong		none
Patients, Consumers
Patient associations	very strong		none

Positions and Influences at a glance

Adoption and implementation

The program was extended to 9 other regions in November 2010 to reach 400 000 patients treated by 17 500 GPs; CNAM has announced that the objective is to generalise these programs in all regions by 2013. The program is financed directly from the sickness fund budget. The annual cost was 10 million Euros for the first year. 

Monitoring and evaluation

The effectiveness and cost effectiveness of this program is being evaluated by a private consultancy firm. The evaluation methods, process and the indicators followed are not very clear yet. The evaluation results will be available by the end of 2010, but the National Insurance Fund has already announced that they will generalise this program to other regions and to other diseases (such as asthma and COPD) without waiting for the evaluation results.

Results of evaluation

By the end of 2010 about 62 000 patients have joined the program (from a targeted 136 000). According to a survey published by the Health Insurance Fund, 80% of the patients who joined the program are satisfied by the services provided. The same survey suggests that 70% of the participating GPs think that the investment of the insurance fund in patient education is a positive thing.

Expected outcome

This policy should contribute to improve the quality of care and life of those patients who participate in this program. This initiative is also a positive step for strengthening patient centeredness of care. However, these types of programs directed to patients using letters and telephone risk suffering from selection bias. The experience of prevention campaigns in other countries shows that patients with higher education levels tend to be more sensitive to this type of campaigns, while those who have low socio-economic status, who are often the ones at more risk of complication, are left behind.

Growing inequalities in health status and health care utilisation is a real problem in France and attention needs to be paid to the needs of the most disadvantaged populations. 

Therefore, the effectiveness and cost-effectiveness of this program should be assessed carefully. There might be room for improving the program design for reaching a larger share of underprivileged population.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

Sophia: le service d'accompagnement de l'Assurance Maladie pour les malades chroniques

www.ameli.fr/professionnels-de-sante/medecins/vous-former-et-vous-informer/sophia-un-service-pour-les-malades-chroniques.php

www.ameli.fr/fileadmin/user_upload/documents/DP_sophia_service_diabetiques_nov2010.pdf

Author/s and/or contributors to this survey

Yann Bourgueil, Zeynep Or

Suggested citation for this online article

Yann Bourgueil, Zeynep Or. "A new plan to improve chronic-disease management". Health Policy Monitor, November 2010. Available at http://www.hpm.org/survey/fr/a16/1