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Monday, October 21, 2013


Lot of questions vie email and Facebook about Saturday's post about my appointment with the plastic surgeon on Friday.  An 18 month wait seem to confirm some idées reçues about "socialized" medicine.

The thing to remember about the French healthcare system is that it's a mixture of public and private.  Most doctors do not work exclusively for the public system.  Some are completely independent and others have a mix of hours at public hospitals, private clinics, and their own practices.

There are two different payment systems here:  state insurance (Assurance maladie) and private insurance companies (mutuelles).  The latter are usually offered as part of a job package (not unlike in the US).  The way it works is that the private insurance is meant to pay for extras that the state insurance does not cover.  A good example would be hospitalization.  Basic state insurance will cover 100% a hospital bed in a room shared by one or two other patients.  If you have private insurance, however, the mutuelle will pay the difference and you can get a private room.

So everyone, regardless of income or status, gets the basic stuff covered by state insurance.  That means that breast cancer treatment is entirely covered - surgery, chemotherapy, radiation therapy, tamoxifen, follow-up appointments, PET scans, MRI's, pain meds - and you never EVER see a bill or have to think for two seconds about how something will be paid for.  Just show your Carte Vitale (state insurance card) and everything is taken care of automatically.  It is incredibly efficient and I am in awe of their ability to provide this kind of cost-effective quality care with a minimum amount of bureaucracy.  Think of it as an "All care, no costly BS" system.

Extra stuff, however, will cost you or the mutuelle, extra.

So what happens with breast reconstruction?

First thing to get clear is that breast reconstruction after a mastectomy is covered by French state insurance.  It's not an extra - it's part of the basic state plan.  That said, the questions are:  how it will be done, when it will be done and where the surgery will occur.

The first question will be answered by me and my surgeon.  There are different options but what it looks like is that I will have to have implants.  I'm just too darn skinny and there isn't enough laine around my middle to use to make two breasts even though I'm not shooting for much here.  I have no desire to look like a Baywatch girl;  I'm thinking more along the lines of an 18th century coupe à champagne designed, they say, using the breast of the Marquise de Pompadour (or Marie Antoinette) as a model.

The when and where are equally complex.  Essentially, I have three options:

1.  The cancer clinic where I have been undergoing treatment now for nearly 2 years.  This was my first choice.  They know me and I know them.  I trust them.  My mastectomy went as well as could be given the circumstances and I still remember the kindness of the surgical team as I went under and the excellent aftercare given by the staff.  These people saved my life.

I can have the surgery done there but it will take 18 months at least before it can happen.  That's the news I got on Friday.  But that's not the last word.  There are other options.

2.  A private clinic that charges reasonable rates.  By "reasonable" I mean one where the bill will not go over what the French state insurances pays and what my private insurance (yes, we have one) will cover.  That's going to require some research and will take time.  There will be paperwork.

3.  A private clinic or plastic surgeon who has an excellent reputation but has fees that will far surpass my coverage.  This would also require research and a cold hard look at the state of our finances.  What is it worth to me and to my spouse to have this done?  5,000 Euros?  10,000 Euros?  20,000 Euros? Who knows.

Now that I am well-rested, well-fed and my head is in a better place, I can start thinking about what I want to do next.  Option 2 is the most realistic and I will start working on that this week.  I can ask both my GP and my gynecologist at the Franciscans here in Versailles for referrals.  If anyone reading this has a plastic surgeon they know and love here in France, please pass on the name.  I'd also really appreciate hearing from any Flophouse reader who has had breast reconstruction. How did it go?  Are you glad you did it?   I'm reading the material they gave me at the hospital and sounds like a lot can go wrong.  Scary, and all for something that is, strictly speaking, not necessary surgery.  Yvonne (Considering the Lilies) posted this photo.  This woman chose not to have reconstruction and instead used the space for a pretty incredible tattoo.  Something to think about...


Blaze said...

I love the tattoo idea. That's definitely thinking outside the bra!

Tim said...

One of the things I find most fascinating is that in the parts of North America I am most familiar with(Toronto and Boston)I have always viewed the healthcare delivery system as being more egalitarian than most of Europe and Asia despite the more capitalistic nature of North America(and Victoria's present situation has confirmed my long held view). Take Boston for example(I will exclude discussion of Toronto for right now as Canada is a much more public system than Europe) in Boston ALL of the best physicians work for the major Hospitals exclusively not their own "private" clinics. The major hospitals Mass General, Brigham's, Beth Israel Deaconess, Tufts Medical, Boston Medical, and Lahey Clinic are all "charities" from a legal perspective.(That is very weird to say as these are all massive and incredibly wealthy institutions). Now on the otherhand I have no idea what healthcare is like in Seattle for example. I do know for example in Florida and New York there are doctors in private practice that don't accept American Medicare and Medicaid however in New England it is a different story.
In Canada private clinics outside of the universal healthcare system are very controversial. I believe in Toronto there are a few however they are generally more common in Vancouver and Montreal(Again I am not that knowledgable about Vancouver healthcare). I will say that in Boston up until 20 years ago there were more of these private clinics but then they were all swallowed up by the major hospitals. Also for non surgical care the major hospital do have satellite suburban locations where they rotate even prominent specialists through a day or two a week. So it is not like you have to go into the city for even the most routing checkup.(I think the satellite suburban locations was one of the things that killed the private clinics).

Christophe said...

Regarding your option #3. Even in the public system, "depassement d'honoraires" is starting to become a widespread problem in France.

This is a tough problem to solve.
It just means that the rate of reimbursement by the public system has not kept up with inflation. We can't blame practitioners for raising their prices.
But who's going to pick up the difference? It's difficult to see the government do it, with the current level of debts.
Are people going to be willing to pay a higher premiums to mutuelles (private additional insurances) if they want cheaper out of pocket costs? It's the tradeoff that all of us face.
In the US, health care consumers have been facing this dilemma for a while, leading to insurances offering different plans with more or less benefits based on the premiums. With health care consumerism increasing in many other developed countries, I would not be surprised if this happened in other places too. Goverments are cash strapped all over the world. It's difficult to see how they can bare more of the cost, for those who have a nationalized health system.

This year, my self insured company even introduced a "high deductible plan", which doesn't make sense to me. It goes against the principle of insurance. Instead of raising the premiums for everyone, we now have the option to get paid (really cheap premium, and the company contributes more than the premium to a Health Savings Account) for basically not being reimbursed at all, up to a high deductible per year. This is playing Russian roulette with what might happen to you.
I think that only healthy young people are going to pick this plan and the financial risks associated with it, living the less healthy people to contribute more to the "normal" plans. They say that they expect several percents saving by having people price shop. It doesn't make sense. You can't always price shop (emergencies for example), and even in non emergency cases, some of the data is highly protected and not public: insurance companies don't make public the prices they negotiate with different providers and guard that like if it was a trade secret.
I don't see how this can work...
The US healthcare system is bound to collapse at some point. In a conversation with a provider not too long ago, his guess was within 5 years.

Good luck with your research. I hope you'll find a clinic that will be able to perform the surgery at a reasonable price an within a reasonable time.

Best wishes.

Rosy said...

The tattoo must have hurt like hell while it was being done. And a weakened immune system is more vulnerable to allergies.

Julia Gandrud (aka JuliaLikesFrogs) said...

Will you have nipples tattooed on? I have heard that many women do this now, at least in the US. Or have nipples reconstructed, and then tattooed the color they want them to be.
I am happy to hear that reconstruction is covered, as it is here. Good luck, Victoria!

Another nice tattoo: