Biological Analyses and Savings on Health Spending

6.7% and drugs increased by 8.9%). Fortunately, though the sickness branch showed a net debt, the global budget for all social security branches showed a credit balance.

After analysis of the national health budget, the Health Ministry announced that health spending in France in 2001 would increase to 148 billion euros or an average of 2,437 euros per inhabitant. Health and medical products costs, the total sum spent by French to care for themselves (reimbursed or not), was 128 billion euros, an increase of 5.8% in value and 5.2% in volume compared to 2000. This represents 8.7% of the gross domestic product (GDP).

A study conducted by the DREES (Direction de la Recherche, des Études, de l’Évaluation et des Statistiques or Research, Study, Evaluation and Statistics Bureau) of the Ministry for Social Affairs published in June 2002, showed that increases in health spending have tended to slow over the last decades in most developed countries but still remain greater than the GDP. According to the OECD (Organization for Economic Cooperation and Development), the percent of revenues devoted to health costs increases as the revenue per inhabitant increases. According to data from 1998, the USA devote 12.9% of their GDP to health spending while that figure is 10.4% in Switzerland, 10.3% in Germany and 9.4% in France compared to 5.3% in Mexico and 4.8% in Turkey. In all developed countries, health spending consistently increased with two criteria: increase in population and aging of the population. In recent years, the estimated effect of demographics and population aging is close to 1% per year in Spain, France, Italy and The Netherlands. These factors are usually not considered in studies though they are far from negligible.

Clinical Analyses impact on Savings on Health Spending

Clinical analyses are important for savings on health spending because they make preventive measures, early diagnosis and better treatment monitoring possible.

Health spending as a proportion of GDP (%) 1970 1980 1990 1999 Germany (a) 6.3 8.8 8.7 10.3 Spain 3.6 5.4 6.6 7.0 (d) USA 6.9 8.7 11.9 12.9 France 5.7 7.4 8.6 9.3 Italy 5.1 7.0 8.0 7.9 The Netherlands 7.2 (b) 8.0 8.5 8.7 (d) United Kingdom 4.5 5.6 6.0 6.9 (a) West Germany from 1970 to 1990, (b) 1972, (d) 1998 Source OECD, Éco-Santé 2000

29

Health Check-up: Biology and Prevention

Insured patients have the right to request a health check-up from their Medical Insurance Fund. This check-up is free of charge when performed in a health examination center managed or approved by the Insurance provider. This request can be made every five years. Once it has received the request, the Insurance Fund sends an invitation and confidential questionnaire about family and personal history and the patient’s current health condition. The contents of the assessment vary with the age, sex and risk factors of the patient. If problems are detected, the examination center will contact the patient’s regular physician. The Paris Medical Insurance Fund (Caisse primaire d’assurance maladie de Paris) also offers health check-ups for children residing in the Parisian region. These check-ups are performed at 10 months, 2 years and 4 years. They included ENT examination, screening for visual and dental abnormalities and laboratory tests. Some tests are systematically performed (complete blood cell count, platelets, urine analysis) while others depend on the age (ferritin to screen for iron deficiency at 10 months, cholesterol at 4 years) or risks observed, such as screening for hereditary hemoglobin abnormalities. According to a study of check-ups performed in 1997, 10% of 10 month-old children and 24% of 4 year-old children were anemic.

Early detection of diabetes in children or adults or of osteoporosis in older patients can prevent complications: kidney problems, arteritis and blindness in diabetic patients, fractures leading to disability in patients with osteoporosis, a common disease in older women.

Each year, 600,000 health check-ups are performed in 80 centers. High cholesterol was discovered in 15% of women and 10% of men over 55 years of age. 2 million patients with diabetes in France: 27,000 diabetes-related deaths. Cost of diabetes treatment: 4.9 billion euros per year.

Biology and Diabetes

Two million individuals currently suffer from diabetes in France (3% of the population). In the overseas departments and territories, 7 to 18% of the population is affected. According to the INVS (Institut National de Veille Sanitaire or National Health Monitoring Institute), almost 27,000 diabetes-related deaths were reported in 1999 (5% of total mortality). The cost of medical treatment for diabetes was estimated at 4.9 billion euros per year, 2.1 billion of which was spent in hospital costs.

30

The prevalence of diabetes is probably underestimated: a portion of the population with diabetes is unaware of the condition. Modifications to behavior such as reduced calorie intake, reduced consumption of saturated fats and increased physical activity, however, are effective methods to slow or even prevent the evolution of this disease.

Monitoring of glycemia and glycated hemoglobin, a protein to which glucose binds, helps control the efficacy of treatment and diet in diabetic patients. A program developed by the CNAM has helped to increase the percentage of diabetes patients not treated with insulin that received at least one dose of glycated hemoglobin per quarter from 41.3% in 1998 to 60.6% in 2000, in accordance with recommendations of the ANAES (Agence Nationale d’Accréditation et d’Évaluation en Santé or National Health Accreditation and Evaluation Agency). During the same period, screening for lipid abnormalities through assays for cholesterol increased as did screening for kidney problems through the assays of serum creatinine levels and microalbuminuria. These problems are common in diabetes patients: without treatment, 50% of diabetes patients were found to present with kidney problems after 15 years of disease evolution.

In 2001, the Health Ministry implemented a program to improve treatment and prevention of diabetes. One of the Ministry’s five objectives was to increase early detection through the development of a nutritional policy, the guarantee of quality care and quality biological monitoring, the improvement of the organization of care and the education of diabetes patients.

31

Biology and Osteoporosis

One-third of post-menopausal women in France suffer from osteoporosis and one out of seven has already experienced a fracture. Each year, 50,000 fractures of the upper extremity of the femur and as many vertebral fractures are diagnosed. The incidence of this disease has been constantly increasing over the last fifty years in both sexes. Due to its prevalence and the consequences for the quality of life and life expectancy of older individuals, osteoporosis is a real sanitary and social problem. Treatments do exist and early detection is necessary. In addition to osteodensitometry, the assay for markers that evaluate bone loss and the risk of fracture is a valuable tool. The main advantages are the possibilities to evaluate treatment efficacy more rapidly than with densitometry and to predict risks of fracture in patients in whom the measurement of bone density is not sufficient to justify the initiation of treatment. These new markers are still rarely prescribed, but are promising for the future.

50,000 femur fractures per year in France. 50,000 vertebral fractures and spinal column compressions. Cost: 4 billion euros per year.

Biology and Infectious Diseases

In light of the increase in infectious diseases, biological analyses are particularly important. An estimated 500,000 to 650,000 individuals are infected with the hepatitis C virus, about 200,000 are unaware of their infection.

In France, between 22,500 and 24,800 individuals are currently suffering from AIDS and approximately 1,700 new cases are detected each year. Lastly, the number of cases of tuberculosis, a disease whose declaration is mandatory, is on the uprise: 6,714 cases were declared in 2000. In Paris alone, 1,060 new cases of tuberculosis were recorded in 2000. Individuals of foreign nationality were the most affected. The incidence was highest in young adults from Sub-Sahara Africa.

In all three cases, the disease can be diagnosed through biological analyses. Molecular biology techniques have helped to drastically reduce the time required for diagnosis of tuberculosis compared to traditional methods. One study showed that when laboratories diagnose patients quicker, physicians provide adequate treatment sooner and mortality was reduced by 31% with important economic benefits. Molecular biology techniques and their use in the fields of genetics and genomics are also promising. We have already mentioned their role in the detection of cystic fibrosis in infants. These techniques are also used for the pre-natal diagnosis in embryonic cells of certain genetic abnormalities such as mental retardation due to fragile X syndrome or Duchenne’s muscular dystrophy. Therapeutic abortion is possible when the fetus is affected.

Diagnosis of tuberculosis using clinical pathology tests: quicker diagnosis (+38%), earlier treatment (+70%), reduced mortality (–31%). Savings estimated to be at least 4,586 euros per patient.

59 couples treated between January 2000 et July 2001. Following the implant of healthy embryos, 12 pregnancies. Birth of 16 children.

Biology and Pre-implant Diagnosis

Pre-implant diagnosis before in vitro fertilization is also possible. Thus, healthy embryos can be implanted into the mother’s uterus, thus allowing the birth of children not suffering from specific diseases. This procedure is strictly controlled: only couples with a high probability of giving birth to a child suffering from a serious genetic disease recognized at the time of diagnosis to be incurable have access to the procedure. Two pre-implant diagnosis centers are

32

currently functional in Paris and Strasburg. A third is planned to open soon.

Biology and Cancer

Cancer studies have also benefited from genetics. Treatment has made considerable progress, though individual responses to anti-cancer treatments and toxicity are quite variable. The expression of certain tumor genes has been found to be associated with increased response to certain treatments, thus making more individualized treatment possible using agents adapted for each patient to better target the molecular particularities of the tumor.

DNA chips, able to identify genetic mutations occurring in all living organisms, are currently the subject of great interest from several industrial groups. These chips are solid supports covered with 10s to 100s of thousands of DNA probes with different sequences. In a few years, these chips will be available to physicians and laboratories and will be used to perform diagnostic tests in a simple drop of blood. They will be used to simultaneously screen for various pathogenic organisms (viruses, bacteria, parasites) and make a more rapid diagnosis, thus allowing earlier initiation of treatment, all from one sample. They can account for the diversity of pathogenic species and the variability of certain viruses.

This is a new challenge for the in vitro diagnostic industry that devotes large amounts of money to the research and development of new products.

Medical Insurance Spending in 2001

Consolidated data from the CNAM, the MSA (Mutualité Sociale Agricole or Social Agriculture Mutual Insurance Company) and the CANAM (Caisse Assurance Maladie des Professions Indépendantes or Insurance Fund for Independent Professions).

Millions euros % increase

Fees 14,134 4.4 Medical 11,898 3.3 Dental 2,236 10.6

Prescriptions 25,397 8.9 Clin. Path. Anal. 2,145 6.9 Drugs 15,609 9.2

Other services (patient transport and other) 2,089 10.2

Services paid in cash 6,483 9.5

Total non-hospital costs 48,103 7.7 In 2001, the costs assumed by the three principal funds will probably represent 95.2% of the corresponding spending of all health insurance funds.

33