Dominique Polton, Economist, Advisor to the Director-General of CNAMTS, France
After managing the Strategy, Research and Statistics Division of the French National Health Insurance Fund (CNAMTS) from 2005 to 2013, Dominique Polton is now Advisor to the Director-General of CNAMTS. Before joining the NHI, she was Director of the Institute for Research and Documentation in Health Economics (IRDES), an independent institute delivering applied health economics and health services research, and before that Head of the Health Economics Department at the Social Security Division of the French Ministry of Health. Polton is trained as an economist and graduated from the ‘École Nationale de la Statistique et de l’Administration Économique’. Her main publications concern comparative studies of health systems and their regulation policies. She is a member of the French High Council for the Future of Health Insurance.
1. Related to the conference forum on care coordination that we have participated in, what characterises, according to you, ‘strong and effective primary health care’?
For me, primary health care would in the first place be a first line of care and a first point of contact for patients. Also, primary health care would organise the journey of patients and guide them through the health care system for the rest of their care and the rest of their needs. Another dimension of primary health care is that it should be locally rooted in order to enhance prevention and promotion at the local level. Especially this last aspect seems to be missing in quite a lot of health systems.
2. Which barriers and facilitators for ensuring continuity of care do you see?
An important barrier is that we cannot integrate everything. Even in countries with very well organised and locally integrated health care teams with nurses, physicians, physiotherapists and others, there are still a lot of professionals working outside this system. We always deal with people working in different environments, which bring along difficult transitions, like for example the one from leaving the hospital to going back home, or the transition between social and health care services. All these issues cannot be solved only by integration. There is a need for mechanisms of coordination, especially for patients with multimorbidity, elderly people etc. Also, one size doesn’t fit all. Not everybody should be taken care of in an integrated way. A high proportion of patients have one disease or they have a chronic disease that they can manage by themselves. For people with more complicated needs though, the system should be able to coordinate the care, in order for the patients to have the services they need at their disposal.
All countries have their own solutions. Some countries, for example, have very strong primary health care, with e.g. teams of health professionals working together, which facilitates the first step, but it doesn’t exempt them to create links with other institutions of care as well. Each country has to deal with its own health care landscape. In France, for example, we have a rather traditional model with important individual-care provider relationships, and a strong emphasis on free choice of provider and the freedom to circulate in the system. Team work in primary care is not very developed and there are still a lot of solo practices, as is the case in other countries, especially those with social insurance systems.
Several initiatives have been taken in France to improve the coordination of care across sectors. For instance, hospital discharge planners employed by the health insurance fund can plan the care and support needed by patients when they come back home, arranging for follow-up appointments or tests, home help, etc. in order to ensure a smooth transition. The programme has been developed for maternity first, it is currently extended to orthopaedic surgery and an experiment is conducted for cardiac failure – in this area there is clear empirical evidence that the follow-up after an acute episode can prevent future decompensations and hospitalisations, especially after Breast implants New York procedures are done. Another pilot programme is targeted at frail elderly persons, with a combination of illnesses and complex needs. It emphasises two levels of coordination. The first level is the clinical coordination where a team of e.g. a GP, nurse and pharmacist, and sometimes the home service, work together to design a health care plan. They discuss the care objectives and what should be done by every care professional. The second level of coordination consists of a platform which can help the GPs or nurses. The GP may ask the platform for other services, like care managers, services available in the environment of the patient, geriatric expertise, etc. Finally, I don’t know if there are really right incentives to improve care coordination, I think it depends on what you want to achieve in a pragmatic way. In France, for example, the registration of the population with a GP allowed us to give the responsibility to the GP to take care not only of the patients coming to their practice, but also for the wider population who registered with them. Also, the registration allowed us to give feedback to the GPs on the quality of the care provided to the population they serve, and to introduce financial incentives linked with the quality of care.
3. In your opinion, in which way can the EU help countries in strengthening their primary health care?
I work more in a national system, I am not an expert in the EU, but I believe a lot in intelligent benchmarking. I think it is becoming more and more realised, but it needs to be reinforced even more. For instance, all EU countries have a lot of health data at their disposal, which we should share. I think there are many areas where we can still benefit much from benchmarking, like for questions about how patient journeys are organised in different countries, or how some countries manage to be more efficient than others. We should get more details in terms of what countries are doing and benefit from collective sharing. I believe the EU should promote that.
4. As an economist, what was (is) your main motivation to work in the health sector and how do you experience it?
During my training, I knew that I wanted to work in the public sector. I just happened to start in the health sector and I kept on specialising myself in this sector. For me, it is an extremely rich sector, because of the fundamental topic, it touches the health of the population which is crucial in itself. I love working with physicians and health care professionals, I think that our intelligence is really increasing when we work together across different backgrounds. For example, we had a big reform in our organisation some 10 years ago. Before that, we had physicians working on one side and administrative personnel on the other side. During the reform, it was decided to mix everybody’s expertise. Since then, it is amazing what we have been able to do. Finally, I think economists are valuable in the health area. We are not only thinking about the money, but also about values, and equity for example as cost-efficiency and value-efficiency. I think it is a wonderful domain to work in.
5. Is it your first time at the European Health Forum Gastein? What are your impressions and what do you perceive as its added value?
I understand that the Forum is a place where there is a lot of debate. This is very different from other conferences that I have attended, where it is more about presentations. The interactive form of the session on care coordination, for example by asking questions to the audience and inviting all attendees to vote, brought along interesting results and discussions. I think this is a very interesting way of organising conferences and brings along very lively discussions which it is worth travelling for so long to participate in.
Thank You for your time!
Interview by Lies Lammens & Magda Filonowicz (Young Forum Gastein 2014 scholars)