Saturday, January 29, 2011

What's Up Doc?

One of my biggest fears about moving to Paris was health care; finding a doctor, which emergency numbers to dial if necessary, knowing the location of the nearest hospital, and how to communicate our needs and problems effectively in a foreign language. Luckily, none of us have any chronic health conditions that need ongoing attention. I really hoped that we would manage to make it through the year without needing to seek medical attention. Wishful thinking. Six months into our life here and we have sought medical assistance twice now. It's been amusingly interesting to compare and contrast the French health care system to that of the U.S.

We averted our first opportunity to access the French health care system in late August when Raelyn's cast, which was due to come off at a doctor's office at the American Hospital outside of Paris, just happened to unravel itself. Actually, it had a little help in the form of Raelyn taking a bath and then peeling it off of her arm, but it saved us from making the trip all the way out to Neuilly sur Seine when what we really hoped for was to find an English-speaking doctor in our neighborhood.

Soon after, we learned that if you ask your local pharmacist, they will give you a referral to a doctor in the neighborhood. No need to call a Member Services department to verify that your desired physician is in-network. All that we wanted and got, easily enough, was a good word from the pharmacist about an Eglish-speaking physician that was in-neighborhood. Soren returned from the pharmacy with a little slip of scratch paper upon which the pharmacist had scrawled the doctor's name, address, and phone number. This little slip of paper provided me with much relief.

By mid-October, we decided that we should take preventative measures, like we do back home every year, and get flu shots. Soren had already received his shot at Kaiser's flu vaccine clinic during one of his business trips back home. Paris, to my knowledge, does not offer any flu vaccine clinics at hospitals or drug stores. Instead, it works like this: First, purchase our flu vaccines at the pharmacy. Each vaccine comes in a small rectangular box stamped with an expiration date. Total cost for three vaccines = 30 euros (Kaiser's flu vaccination clinics = $0). Second, refrigerate the vaccines at home until our appointment time. Third, call and schedule the vaccination appointment with the doctor. Soren did a great job of managing to arrange our appointment in French because the receptionist that answered the phone did not speak English. Finally, arrive at our appointment with our baggie of vaccines. Can you imagine this system in the U.S.? Patients responsible for purchasing, storing, and transporting their own vaccines? We even heard that some French people skip the doctor's visit altogether and simply inject themselves at home. No thank you.

Upon arriving at the doctor's building, we press the door buzzer to notify him that we have arrived. The building's door buzzes and we enter. We ascend one flight of stairs and reach his office door. The doctor's waiting room, on the other side of this door, is small; a few chairs, an end table with magazines, and a coat rack. What is missing is a receptionist behind a counter, the front office of the doctor's office (a.k.a., the Gatekeeper). With no one to check-in with and officially announce our arrival, we take a seat and wait. Just a few minutes later (as opposed to Kaiser's standard 20 minutes) another door opens and Dr. Bomhof introduces himself to us and ushers us into his office. There is a desk, an exam table, and a credenza filled with books. The doctor takes a seat behind his desk, invites us to take a seat, and we proceed to get acquainted.

Dr. Bomhof  is Dutch, he studied medicine in Paris, and has been here ever since. He is pleasant and personable, his English is excellent. He asked us lots of questions, not about our health history, but about where we are from and what brings us to Paris. The short answer is always, "Because of my husband's work." We never get away with the short answer. It always turns into answering, "What line of work is that?" and then the French are even more curious when they learn Soren is self-employed (entrepreneurs are a rare breed in France) and not an employee of a big company that has stationed us as expats in Paris. Follow-up questions usually include, "Why Paris?", "How long?", and my personal favorite directed at me, "And, what do you do?" Um, it's called trying to raise two decent human beings.

I had read in one of my books that the French are not into asking about what one does for a living, but rather, what one is. From their perspective however, it is typical for French mothers to have a career, most here do. What they don't understand, however, is that I am not offered government-subsidized child care in my country and that the costs of childcare would likely outweigh my earning potential, not to mention that with a husband who travels a ton, paying somebody else to raise our kids so that I can have a career isn't a choice that works for me. I guess it's just another way of saying that I want to be sure it is my presence that sends my kids to therapy someday rather than my absence.

After concluding our lengthy introduction (a far cry from Kaiser's 10-minute total visit rule), Dr. Bomhof wants to know why we are interested in receiving the flu vaccine. Short answer: Because we get it every year. "But why?" he inquires, "You are young and healthy, no?" Long answer: Because the U.S. medical profession tell us to, Soren spends a lot of time on planes, and we don't want to get sick and visit you more than we have to. The doctor chuckles. He explains that very few French (under the age of 60) receive an annual flu shot and, in fact, last year, with the H1N1 scare, France organized a flu vaccine campaign that wound up being poorly-received and many vaccinations went to waste. He humored us since we had gone to the trouble of purchasing, refrigerating, and presenting our vaccines to him and injected us despite that fact that he thought we were being a bit silly and overcautious. Total cost for three injections = 50 euros (per-visit copay at Kaiser per our plan = $100. We elected a Kaiser plan with a lower monthly premium but higher copays in order to ensure greater inpatient and long-term care coverage. We see the doctor so infrequently, but every time we do, I think, 'ouch'!). Dr. Bomhof said that we can choose to pay him cash on the spot or send him a check. We payed cash and he wrote a receipt. No front office necessary apparently. I began to wonder where he is hiding the French receptionist that Soren had spoken to originally.

Fast-forward to mid-January. It is the night before the girls and I are to depart on a train headed to Brugges, Belgium. Soren, who has been in the Netherlands, is meeting us there during his weekend break from teaching at the university in Breda. I was in the kitchen cooking dinner when I hear a shrill scream and loud crying coming from the dining room. It turns out that Nola has been attacked by two dining chairs. One hit her on the back of her head, the other one simultaneously crashed into her nose. I find her crumpled on the floor lying amidst the felled chairs while cradling her head and nose in her hands. She has a huge bump on the back of her head and a gash across the bridge of her nose that is bleeding while it begins to swell (for the unusual story about how this injury occurred, check out Nola's blog: After assessing that her cut did not require stitches, she sat icing her injuries while I googled information about broken noses. Based on what I read, I made an initial judgement call that her nose was not broken. My motto became, 'Have Ibuprofen and BandAids, Will Travel', and off we went to our weekend in Brugges. Nola was a trooper, BandAid and all.

By the time we returned on Sunday evening, I was beginning to doubt my initial assessment and began to worry that her nose might indeed be broken. On Monday morning, Soren called Dr. Bomhof's office from the Netherlands, expecting to reach the French receptionist, but no one answered the phone, it just rang and rang. At least with Kaiser, the phone is answered, even if you are just listening to Muzak while waiting your turn in the queue, knowing that eventually, someone will pick up. Even if it is to put you back on hold again. Not that I would equate this with true customer service, but at least it's a step in the right direction. The French don't even try to grasp the concept of customer service (except for 5-star hotels and Michelin-rated restaurants) and not receiving a live person or automated greeting at the doctor's office was just another example of this. Soren called again on Tuesday, the phone was answered by the receptionist and he succeeded in making an appointment for Nola.

When we arrived, we again waited only a few minutes in his waiting room and Dr. Bomhof and I carried on a nice conversation about Brugges and the Netherlands while he examined Nola. He directed me to take her for an x-ray. My insides immediately tightened up because I felt fearful leaving the comfort and confines of nice English-speaking Dr. Bomhof's office and venturing out into the wider circle of French health care. The doctor made it sound simple enough. He simply placed a call to his radiologist colleague and informed him of our impending arrival, gave me his address (which was only a block away) and a medical form, and off we went. I was instructed to return to Dr. Bomhof's office directly from the radiologist's.

When we arrived at the radiologist's office, I was initially confused as to where to go and to whom I present Nola's form. We were inside an 18th century building that was clearly a former home. The living room was now a waiting room (complete with original wood floors, fireplace, and crown mouldings) and the former dining room was the front office. There was nothing 'front' about this front office at all because it was separated from the waiting room by a grand staircase and had I not had the girls help translate the signs on the wall for me, we would have remained seated in the waiting room for who knows how long. After all, I was already accustomed to Dr. Bomhof's system of no front office receptionist.

We approached the receptionist and I apologized to her, "Désolé, mon français est terrible. Nous sommes ici pour ma fille, Nola." I handed her the form and she asked me, "Vous avez la carte vitale et la sécurité sociale pour Nola?" I swallow the gulp forming in my throat and simply reply, "Non." I begin to worry that she is judging me as an unfit mother, showing up to an appointment without the necessary documents. I found myself wondering if I will be able to understand her when she tells us that we will have to come back another day with the appropriate documentation. I quickly speak up in the hopes of preventing such a scenario and state, "Je paie avec cash, si vous plait." Money talks, right? And a si vous plait never hurts. Cost of xray = 32.40 euros (as opposed to another $100 Kaiser copay). Next thing I knew, she handed me a form and directed us to wait our turn in the waiting room. Thirty minutes and one xray later, we returned with xray in hand to Dr. Bomhof's waiting room. A young man was already seated and five minutes later when the doctor opened his office door, he explained to this patient, in French, to please be patient, he is going to see the child first. I was already fond of Dr. Bomhof, but this preferential treatment sealed the deal.

One look at Nola's x-ray confirmed that my initial assessment was correct. Not broken. Phew! I now gave myself permission to stop feeling guilty about taking our broken-nosed child on a weekend trip to Brugges. Dr. Bomhof wrote a note excusing Nola from her physical activities for the upcoming week and gave us the x-ray to take home. In France, the patient is responsible for keeping and maintaining all medical records. So Nola is now the proud owner of a really cool head shot. Total cost of Dr. Bomhof's exam = 40 euros (again, better than our customary $100 copay).

We received an explanation today, from one of Soren's relatives, about the carte vitale and sécurité sociale that the radiologist's office asked for. The French citizen's carte vitale is their basic health insurance card that covers them for basic medical care. The card is embedded with a microchip and contains one's social security insurance details. The card is presented to the doctor who places it into a card reader enabling direct reimbursement from the insurance fund. Reimbursements are placed directly into one's bank account, normally within a week.

This relative explained that, as French citizens, the incurred costs of the girls' care would be reimbursed to us at 50-70%  had we been able to present this identification. Soren too, is eligible as a French citizen. But, we have chosen to fly under the radar, so-to-speak, since his income is not derived from France and therefore he does not pay into France's social security system. This means we are uninsured here in France.

Let's just say, for the sake of comparison, that Nola and Raelyn did possess a French-issued insurance card linked to a French social security number. That means that our total out-of-pocket medical expenses (after reimbursement at 50% for the past six months) would total 74 euros. This total even includes my non-reimbursable flu innoculation cost since I am non-citizen. That's a far cry from the $300 in copays we would have incurred with Kaiser for the same treatment. Not to mention, that a U.S. primary care physician would not do an initial intake with new patients as a family like Dr. Bomhof did with the four of us. Each of us would have had to be seen individually and incur individual copays for these initial visits. How much would it cost for an  uninsured U.S. citizen to receive an exam from a primary care physician and obtain an x-ray from a radiologist? My guess is substantially more than $100 (calculated exchange rate). Based on this alone, it is easy to see how and why France has been described by the World Health Organization for providing the best overall health care in the world. I sure wish U.S. policy-makers would try a dose of this medicine.


  1. Loved this Holli - but to be fair you need to include the $$ the french pay in taxes to receive their carte vitale. I would be interested to hear how much someone makes per hear and how much they pay in taxes? With our taxes going up we must be approaching the socialized tax % ? Very interesting about the flu shot - my kids got it this year, we did not (but did last year) and our pediatrician told us he did not think it was working this year! We have all been sick this month - but Alborz & I NOT with the flu, Keyan not sure....Miss you guys!!!

  2. Good point Laurie. The French universal health care coverage is extended to all legal residents and the entire population must pay compulsory health insurance. A premium is deducted from one's income automatically and the set rate I think is about 5.5% of earned income. Gambling taxes are also directed towards health care. The French government covers 79% of health care costs as opposed to the U.S. rate of 45%. In addition, French patients have the freedom of choice about where to receive care.