Strategic intelligence monitor on personal health systems, phase 3 (SIMPHS 3) : MACVIA-LR (France), case study report.
Date: 2015-03-20
Institutions: Institute for Prospective Technological Studies
Subjects: France, case study, chronic illness, data collection, health care, health care system, health policy, information technology, new technology, organisation of health care, population ageing, public health, research report

Strategic Intelligence Monitor on 
Personal Health Systems Phase 3 
(SIMPHS3) 

MACVIA-LR (France) 
Case Study Report 

Authors: Jean Bousquet, Jacques Mercier, 
Antoine Avignon, Rodolphe Bourret, 
Thierry Camuzat 

Editor: Fabienne Abadie 

2 0 1 5  

Report EUR 27150 EN 

 
 
 
 
 
European Commission 
Joint Research Centre 
Institute for Prospective Technological Studies  

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EUR 27150 EN 

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Abstract 
The  MACVIA-LR  integrated  care  approach  deployed  in  the  Languedoc-Roussillon  region  in  the  South  of  France  rests  on 
three  main  initiatives  that  put  particular  emphasis  on  the  prevention  of  unhealthy  ageing  of  patients  suffering  from 
chronic conditions by implementing a series of actions that range from the early diagnosis and management of chronic 
respiratory diseases to the detection of un-recognised co-morbidities. The initiatives form part of a set of activities as a 
reference site for the European Innovation Partnership on Active and Healthy Ageing initiative in the Languedoc-Roussillon 
region  and  comprise:  Integrated  care  pathways  for  airway  diseases  (AIRWAYS  ICPs);  Allergic  Rhinitis  and  its  Impact  on 
Asthma (ARIA); and the Co-morbidity Clinics. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preface 

The Strategic Intelligence Monitor on Personal Health Systems (SIMPHS) research started in 
2009 with the analysis of the market for Remote Patient Monitoring and Treatment (RMT) 
within Personal Health Systems (PHS). This approach was complemented in a second phase 
(SIMPHS2)  with  the  analysis  of  the  demand  side,  focusing  on  needs,  demands  and 
experiences  with  PHS  by  healthcare  producing  units  (e.g.  hospitals,  primary  care  centres), 
healthcare professionals, healthcare authorities and patients amongst others.  

Building on the lessons learnt from SIMPHS2  and on the European Innovation Partnership 
on Active and  Healthy  Ageing  initiative, SIMPHS3 aims to explore the factors that lead to 
successful  deployment  of  integrated  care  and  independent  living,  and  define  best 
operational  practices  and  guidelines  for  further  deployment  in  Europe.  This  case  study 
report is one of a series of case studies developed to achieve these objectives. 

The outcomes of SIMPHS2 are presented in a series of public reports which discuss the role 
of governance, innovation and impact assessment in enabling integrated care deployment. 
In  addition,  through  the  qualitative  analysis  of  twenty  seven  Telehealth,  Telecare  and 
Integrated  Care  projects  implemented  across  twenty  regions  in  eight  European  countries 
investigated  in  SIMPHS2,  eight  facilitators  have  been  identified,  based  on  Suter’s  ten  key 
principles for successful health systems integration.  

The eight main facilitators identified among these as necessary for successful deployment 
and adoption of telehealth, telecare and integrated care in European regions are:  

Interoperable information systems 

  Reorganisation of services, 
  Patient focus, 
  Governance mechanisms, 
 
  Policy commitment, 
  Engaged professionals, 
  National investments and funding programmes, and  
 

Incentives and financing.  

These  eight  facilitators  have  guided  the  analysis  of  the  cases  studied  in  SIMPHS3  and  a 
graph showing the relative importance of each facilitator is presented in each case study. 

In  addition  to  the  above  facilitators  analysed  in  each  case  report,  a  specific  section  is 
dedicated  to  the  analysis  of  care  integration.  It  should  be  noted  that  the  definition  of 
vertical  and  horizontal  integration  used  in  this  research  is  taken  from  the  scientific 
literature  in  the  field  of  integrated  care1 and  differs  from  the  one  mentioned  in  the 
European  Innovation  Partnership  on  Active  and  Healthy  Ageing  Strategic  Implementation 
Plan.2 We define horizontal integration as the situation where similar organisations/units at 
the same level join together (e.g. two hospitals) and vertical integration as the combination 
of different organizations/units at different level (e.g. hospital, primary care and social care).  

1   Kodner, D. (2009). All together now A conceptual Exploration of Integrated Care.  
2   http://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/steering-

group/operational_plan.pdf (page 27) 

1 

 
 
                                              
Table of contents 

CASE OUTLOOK .................................................................................................................................................. 4 

1  BACKGROUND ............................................................................................................................................. 6 
FRANCE SOCIAL WELFARE AND HEALTH CARE SERVICES ............................................................................................. 6 
LANGUEDOC-ROUSSILLON REGION .................................................................................................................................. 8 
FIGHTING CHRONIC DISEASES FOR ACTIVE AND HEALTHY AGEING IN THE LANGUEDOC-ROUSSILLON 
REGION .................................................................................................................................................................................... 9 

1.1 
1.2 
1.3 

2 

INTEGRATED CARE ANALYSIS ............................................................................................................. 10 
DIMENSIONS ....................................................................................................................................................................... 10 
IMPACT ................................................................................................................................................................................. 10 
DRIVERS AND BARRIERS ................................................................................................................................................... 11 
ORGANISATION, HEALTH PROFESSIONALS AND PATIENTS ........................................................................................ 12 
INFORMATION AND COMMUNICATION TECHNOLOGIES ............................................................................................. 13 
GOVERNANCE ...................................................................................................................................................................... 14 
ORGANISATIONAL PROCESSES ........................................................................................................................................ 14 
REIMBURSEMENT MODEL AND ECONOMIC FLOW ....................................................................................................... 16 

2.1 
2.2 
2.3 
2.4 
2.5 
2.6 
2.7 
2.8 

3  TRANSFERABILITY .................................................................................................................................. 16 

4  CONCLUSION ............................................................................................................................................ 18 

REFERENCES .................................................................................................................................................... 20 

2 

 
 
 
 
 
 
LIST OF TABLES 

Table 1:  

General information about Languedoc-Roussillon .................................................................................. 9 

Table 2:   MACVIA-LR stakeholders ..................................................................................................................................... 12 

Table 3:   Members of AIRWAYS ICPs ................................................................................................................................ 17 

LIST OF FIGURES 

Figure 1:  

French health system characterisation ......................................................................................................... 7 

Figure 2:  

The Languedoc-Roussillon region ..................................................................................................................... 8 

Figure 3:   Areas of implementation of MACVIA-LR .................................................................................................... 13 

Figure 4:   Uniform approach to the severity of allergic diseases ...................................................................... 15 

Figure 5:   Chronic disease clinic to assess co-morbidities ..................................................................................... 16 

Figure 6:   MACVIA-LR integrated care facilitators ...................................................................................................... 19 

3 

 
 
 
 
Case outlook 

The  MACVIA-LR  integrated  care  approach  deployed  in  the  Languedoc-Roussillon  region  in 
the  South  of  France  rests  on  three  main  initiatives  that  put  a  particular  emphasis  on  the 
prevention  of  unhealthy  ageing  of  patients  suffering  from  chronic  conditions  by 
implementing a series of actions that range from the early diagnosis and management of 
chronic respiratory diseases to the detection of un-recognised co-morbidities. The initiatives 
form part of a set of activities as a reference site for the European Innovation Partnership 
on  Active  and  Healthy  Ageing  (EIP  on  AHA)  in  the  Languedoc-Roussillon  region  and 
comprise:  integrated  care  pathways  for  airway  diseases  (AIRWAYS  ICPs);  Allergic  Rhinitis 
and its impact on Asthma (ARIA); and Co-morbidity Clinics. 

The first initiative, AIRWAYS ICPs, aims to launch a collaboration to develop multi-sectoral 
care  pathways  for  chronic  respiratory  diseases,  and  to  scale  these  up  globally  in 
accordance  with  the  WHO  Global  Alliance  against  Chronic  Respiratory  Diseases  (GARD). 
ARIA  -  the  most  widely-used  guideline  for  allergic  rhinitis  and  asthma  comorbidity  -  has 
been implemented in the Languedoc-Roussillon region to reduce the burden of allergy and 
asthma across the life-cycle, allowing individuals to age more actively and healthily. Lastly, 
the  Co-morbidity  Clinics  initiative  comprises  a  pilot  study,  and  multi-sectoral  Integrated 
Care Pathways for chronic disease based on a co-morbidity clinic. It has been deployed in 
remote  rural areas  and aims  to achieve  a reduction of 20% of avoidable  hospitalisations 
for chronic patients. 

The  focus  of  the  services  provided  through  the  initiatives  rests  on  preventive  care  and 
chronic  disease  management  through  the  provision  of  integrated  care  pathways.  These 
pathways  imply  a  clinical  integration  as  regards  the  provision  of  services  through 
organisational integration, especially between primary care and hospitals, and professional 
integration  among  GPs  and  specialists.  It  establishes  close cooperation  between  different 
organisational  levels  which  facilitates  the  coordination  of  care,  and  improves  health  care 
processes and outcomes for patients. 

MACVIA-LR has launched a series of integrated Living Labs (e.g. health and disease, health 
and  innovation,  health  and  autonomy)  for  real-life  tests  in  an  experimental  environment, 
where  users and producers  can co-create innovative solutions.  These Living Labs work as 
enablers of change by putting patients at the centre of the MACVIA-LR initiative. 

All  elements  of  the  MACVIA-LR  have  been  implemented  at  least  in  pilot  studies  and  are 
now  ready  to  be  deployed  in  the  region,  particularly  in  more  remote  areas.  Although  an 
evaluation of the business case has yet to be carried out, the approach undertaken in the 
MACVIA-LR  case  seems  to  be  a  promising  solution  for  the  reduction  of  avoidable 
hospitalisations in the Languedoc-Roussillon region in the South of France.  

This approach has yet to be fully exploited, however, and it remains to be seen whether it 
can be transferred to other contexts in France and Europe.  

4 

5 

 
 
1  Background 

1.1  France social welfare and health care services 

The French health care system  offers universal coverage, and all residents are entitled to 
access  publicly-financed  health  care  provided  through  non-competitive  statutory  health 
insurance  (SHI)  funds.  Three  major  SHI  funds  cover  more  than  90%  of  French  salaried 
employees, rural workers or self-employed. The state covers the health insurance costs of 
residents not eligible for SHI. The delivery of care is shared among private, fee-for-service 
physicians, private hospitals (both profit and non-profit making) and public hospitals. Next 
to  the  health  care  and  social  sector,  the  French  health  system  also  covers  a  third  sector 
providing  care  and  services  to  the  elderly  and  disabled.  The  health  system  is  largely 
regulated  by  the  state  through  the  Parliament,  Government  and  Administration  of  Health 
and  Social  Affairs,  and  the  SHI  and  to  some  extent  by  local  communities  at  the  regional 
level. In 2009, a regional health agency (ARS) was established to ensure that health care 
provision  corresponds  to  population  needs  by  means  of  improved  coordination  among 
ambulatory and hospital sectors, in line with national health expenditure objectives.  

The  SHI  covers  a  broad  range  of  services  provided  by  GPs  and  specialists,  but  does  not 
cover  all  expenditures.  About  90%  of  the  population  can  contract  complementary  or 
supplementary voluntary health insurance (VHI) either through employers or means-tested 
vouchers to cover services not addressed by the SHI. The level of both contributions made 
to  and  benefits  received  from  each  fund  vary.  The  contracts  can  also  differ  in  terms  of 
level  of  coverage  of  the  costs  that  patients  have  to  bear  after  SHI  reimbursement.  In 
general  terms,  the  VHI  provides  reimbursement  for  additional  payments  or  co-payments 
made  by patients  and includes a better  coverage of medical goods  and services that  are 
poorly covered by the SHI.  

In terms of service provision, the SHI funds cover hospital care and treatment in public or 
private rehabilitation and outpatient care provided by GPs, specialists, dentists or midwives. 
These  funds  also  cover  diagnostic  services,  prescription  of  drugs,  medical  appliances  and 
transport.  In  addition,  long-term  and  mental  health  care  services  are  partially  covered  by 
the SHI, and there is a minimum coverage of outpatient vision and dental care.  

Since 2004, the Ministry of Health has defined the SHI benefit package, its price and cost-
sharing  levels,  in  cooperation  with  the  statutory  health  insurers.  The  benefits  provided 
under the SHI are defined, however, differently for outpatient and inpatient care. Outpatient 
services  that  are  covered  by  the  SHI  are  determined  at  national  level  and  applied 
throughout  France.  The  coverage  of  medical  devices  and  drugs  is  determined  by  the 
Ministry of Health and the SHI determines the procedures applicable to service provision. As 
regards  inpatient  hospital  care,  a  range  of  services  are  provided  to  patients  under  a 
diagnosis-related reimbursement scheme.  

The SHI is financed by employer and employee payroll taxes (43%), a national earmarked 
income tax (33%), revenue taxes levied on tobacco and alcohol (8%), transfers from other 
branches  (8%)  and  state  subsidies  (2%).  The  funds  are  pooled  on  the  national  level  and 
allocated through the national budgets determined by the Parliament. Within each budget, 
a regional allocation is decided upon and distributed by the regional health agency. Health 
care costs account for about 85% of SHI expenditure, while around 15% are spent as cash 
benefits  through  daily  allowances  for  maternity,  sickness  or  occupational  accident  leave 
and disability pensions.  

6 

Most  physicians  in  France  work  on  a  self-employed  basis.  More  GPs  than  specialists  are 
self-employed and most of them work in solo practices. The providers are paid by the SHI 
or  directly  by  patients  and  the  statutory  tariffs  are  established  through  negotiations 
between providers and the SHI with prior approval from the Ministry of Health.  

Figure 1: French health system characterisation 

Source: Chevreul et al. (2010) 

7 

 
 
 
 
 
1.2  Languedoc-Roussillon region 

The  mission  of  the  Languedoc-Roussillon  region  (budget  of  €1.2  billion,  3,200  members) 
encompasses  education,  training,  economic  development,  long-term  national  and  regional 
development, research and public health. The region has made large investments in training 
on  health  and  primary  prevention  (e.g.  a  health  education  programme  for  15-25  years 
olds), emphasising the role of social care. The region supports many research programmes, 
particularly  in  biosciences,  and  it  is  among  the  five  best  French  centres  of  public/private 
research.  Health and social equity is a key issue and the region finances a specialised care 
programme  (“maison  médicale  pluridisciplinaire”)  in  remote  rural  areas,  an  information 
programme on health for the elderly and an evaluation of interoperable independent living 
solutions.  The  region  is  a  member  of  the  GECT  Pyrénées-Méditerranée,  co-manager  and 
delegated manager of European funds and was first in launching JEREMIE (Joint European 
REsources for MIcro-to-medium Enterprises). 

Figure 2 displays the geographical location of the Languedoc-Roussillon region. 

Figure 2: The Languedoc-Roussillon region 

Source:  Author’s elaboration. 

The region covers an area of about 27,376  km2 and has a population density of about 98 
inhabitants per km2, with a total of about 2.73 million inhabitants living in the region.  The 
region  has  132  GP’s  and  105  specialists,  and  865  health  care  professionals  per  1,000 
inhabitants.  Table  1  summarises  the  main  socio-economic  data  of  the  Languedoc-
Roussillon region.  

8 

 
 
 
 
Table 1: General information about Languedoc-Roussillon  

Geographical coverage, km2 
Inhabitants per km2 
Number of inhabitants 
Life expectancy at birth, years 
Regional GDP (2012), € billion 
Regional GDP per inhabitant (2012) €/inhabitants 
General Practitioners /1,000 inhabitants (2010) 
Specialists /1,000 inhabitants (2010) 
Health care professionals / 100,000 inhabitants 
Hospital beds (2012) 
Hospital beds/1,000 habitants (2012) 

27,376 
98 
2,727,286 
81.5 
63.9 
23,566 
132 
105 
865 
18,675 (2011) 
38.5 

Source: INSEE, DREES, ARS 

1.3  Fighting  Chronic  Diseases  for  Active  and  Healthy  Ageing  in  the  Languedoc-

Roussillon region 

MACVIA-LR has launched several initiatives as part of its activities as a reference site under 
the  EIP  on  AHA  in  the  Languedoc-Roussillon  region.  The  case  study  at  hand  focuses  on 
three  main  initiatives:  integrated  care  pathways  for  airway  diseases  (AIRWAYS  ICPs), 
Allergic Rhinitis and its impact on Asthma (ARIA), and the co-morbidity clinics. 

The first initiative, AIRWAYS ICPs, aims to launch a collaborative effort to develop multi-
sectoral care pathways for chronic respiratory diseases which could be scaled up globally in 
accordance with the WHO Global Alliance against Chronic Respiratory Diseases (GARD). This 
initiative  includes,  among  others,  the  development  of  a  common  framework  of  care 
pathways  for  chronic  respiratory  diseases,  which  will  facilitate  comparability  and  trans-
national  initiatives,  as  well  as  the  development  of  plans  targeted  at  various  population 
groups  according  to  culture,  health  systems  and  income.  At  the  same  time,  it  strives  to 
build  a  sentinel  network  for  allergic  diseases  and  asthma  which  could  have  a  significant 
impact on the health of citizens in the short-term (e.g. reduction of morbidity, improvement 
of children's education and reduction of absenteeism) and the long-term (healthy ageing), 
while  reducing  the  healthcare  burden  (e.g.  emergency  visits,  avoidable  hospitalisations, 
disability and costs). It could also improve quality of life by promoting  active and healthy 
ageing. 

The second initiative, ARIA - the most widely-used guideline for allergic rhinitis and asthma 
comorbidity3 -  has  been  implemented  in  the  Languedoc-Roussillon  region  with  a  view  to 
reducing  the  burden  of  allergy  and  asthma  across  the  individual's  life-cycle  thereby 
allowing  more  active  and  healthier  ageing.  This  initiative  includes  the  development  of  a 
sentinel  network  (MASK)  to  study  the  symptoms  of  patients  suffering  from  allergic 
symptoms during the pollen season. It also makes them sentinels  who warn of  the onset 
and the level of severity of the pollen season. Patients are geo-localised and evaluate their 

3   Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic Rhinitis and its Impact on 
Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). 
Allergy. 2008;63 Suppl 86:8-160. 
Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Allergic Rhinitis and its 
Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126(3):466-76. 
Bousquet J, Schunemann HJ, Samolinski B, Demoly P, Baena-Cagnani CE, Bachert C, et al. Allergic Rhinitis 
and its Impact on Asthma (ARIA): achievements in 10 years and future needs. J Allergy Clin Immunol. 
2012;130(5):1049-62. 

9 

                                              
symptoms by  means of the  Visual Analogue Scale (VAS), using a cell phone with a touch 
screen,  or  internet.  This  information  is  coded  and  sent  to  a  central  database  and 
subsequently  to  all  patients  registered  in  the  system.  A  Clinical  Decision  Support  System 
(CDSS)  immediately  proposes  advice  for  (standardised)  pharmacological  treatment.  This 
sentinel network is also supported by a network of pharmacists who have received a tool to 
help  them  give  optimal  advice  to  patients  with  allergic  rhinitis,  including  diagnosis,  OTC 
(over-the-counter) treatment and referral to a physician.4 

Lastly, the Co-morbidity Clinics initiative comprises a pilot study and multi-sectoral ICPs 
for  chronic  diseases  established  by  a  co-morbidity  clinic.  It  is  being  deployed  in  remote 
rural areas and aims to achieve a 20% reduction in avoidable hospitalisations for chronic 
patients.  This  intervention  includes  a  one-day  clinical  assessment  performed  through  an 
evidence-based list of criteria (e.g. questionnaires, examinations, biological biomarkers for 
chronic  diseases) for: (i) the screening of co-morbidities  of cardiovascular  diseases (CVD), 
COPD or Type 2 diabetes (D2M); (ii) the prediction of their exacerbations; and (iii) the overall 
estimation  of  severity.5 This  common  list  is  used  for  all  patients  referred  to  the  clinic.  A 
mobile  clinic  has  been  set  up  with  interoperability  with  the  co-morbidity  clinic  in  order  to 
screen co-morbidities in the remote rural areas of the region. 

2  Integrated care analysis 

2.1  Dimensions  

Although  the  MACVIA-LR  Fighting  Chronic  Diseases  for  Active  and  Healthy  Ageing  in  the 
Languedoc-Roussillon  region  initiative  targets  the  entire  population  in  the  area,  the  three 
initiatives  outlined  above  place  a  particular  emphasis  on  the  prevention  of  unhealthy 
ageing  of  patients  suffering  from  a  chronic  condition,  including  patients  with  complex 
illness, by implementing a series of actions ranging from early diagnosis and management 
of chronic respiratory diseases to the detection of un-recognised co-morbidities.  
The  focus  of  the  services  rests  on  preventive  care  and  chronic  disease  management 
through integrated care pathways. These pathways imply a clinical integration  as regards 
the  provision  of  services  through  organisational  integration,  especially  between  primary 
care  and  hospitals,  as  well  as  professional  integration  among  GPs  and  specialists. 
Therefore it involves the collaboration of different organisations at different levels. This in 
turn  means  that  vertical  integration  is  also  achieved,  as  providers  work  together  to 
facilitate  the  coordination  of  care,  and  improve  health  care  processes  and  outcomes  for 
patients. 

2.2 

Impact 

All  elements  of  the  MACVIA-LR  have  been  implemented  at  least  in  pilot  studies  and  are 
now  ready to be  deployed in  the region, particularly in more  remote areas.  However, the 
business  case  has  not  yet  been  evaluated.  Nevertheless,  a  positive  outcome  can  be 
expected,  since  MACVIA-LR  aims  to  reduce  avoidable  hospitalisations  in  the  region.  This 

4   ARIA in the pharmacy: management of allergic rhinitis symptoms in the pharmacy. Allergic rhinitis and its 

impact on asthma. Allergy. 2004;59(4):373-87. 

5   Bousquet J, Jorgensen C, Dauzat M, Cesario A, Camuzat T, Bourret R, et al. System Medicine Approaches 

for the Definition of Complex Phenotypes in Chronic Diseases and Ageing. From Concept to 
Implementation and Policies. Curr Pharm Des. 2014. 

10 

 
                                              
indicator  can  be  easily  measured  and  a  baseline  has  already  been  obtained.  Other 
indicators  include  healthy  life  years  (for  which  a  tool  is  currently  under  development  for 
different regions including Languedoc-Roussillon), and health outcomes such as quality-of-
life and frailty. 

2.3  Drivers and barriers  

All  stakeholders  operating  within  the  Languedoc-Roussillon  region  are  involved  in  the 
MACVIA-LR,  which  includes  the  different  actors  of  the  French  Health  System  (e.g.  ARS, 
CPAM6, and CARSAT7). There is wide consensus among these actors about the urgent need 
to  change  the  management  of  the  health  system  for  chronic  diseases.  More  specifically 
they  acknowledge  the  importance  of  primary  care  as  the  front  line  for  optimal  care 
provision  on  the  basis  of  adequate  public  health  strategies  and  the  development  of  IT 
systems which support integrated care and shared decision-making, taking account of both 
patients’  values  and  preferences  as  well  as  inter-professional  collaboration.  This  shared 
vision drives the MACVIA-LR initiatives for more integrated care services provision.  

It  is  worth  mentioning  that  most  of  the  components  mentioned  above  already  exist  in 
Languedoc-Roussillon,  but  that  the  integrated  care  dimension  has  not  been  tested  in  the 
rest of France. In this respect, MACVIA-LR has launched a series of integrated Living Labs 
(e.g.  on  health  and  disease,  health  and  innovation,  health  and  autonomy)  for  real-life 
testing  in  an  experimental  environment,  where  users  and  producers  can  co-create 
innovative solutions. These Living Labs work as enablers of change by putting patients at 
the  centre  of  the  MACVIA-LR  initiative.  However,  this  novel  approach  is  not  yet  fully 
understood by all  actors, which makes it highly  important to  disseminate the information 
on a local level and to explain the potential benefits of the approach. 

An  economic  evaluation  of  the  initiatives  is  essential  and  MACVIA-LR  represents  a 
completely new approach in this respect. Single components, including services provided by 
the novel co-morbidity clinic, are fully reimbursed, but the full MACVIA-LR approach is not. 
This could hamper integrated care development and consequently have detrimental effects. 
The Sécurité Sociale is still investigating how to reimburse the programme, as it is relatively 
easy to assess the cost-benefit interventions for a single disease but far more difficult to 
assess  the benefits of tackling co-morbidities,  which are not  always easy to  demonstrate 
from a clinical point of view.  

As a consequence, this could represent a barrier for further deployment. Nevertheless, it is 
difficult  to  discuss  policy  support  for  the  deployment  of  the  initiative  and  the  potential 
resistance from care managers, especially at this stage. It is evident that in the Montpellier 
CHRU case,  the  programme  is  fully  supported by  care  managers.  In  this  case  an  attempt 
was  made  to  re-organise  the  service  with  a  minor  increase  in  the  workload  of 
professionals,  including  the  social  care  workers,  who  have  shown  no  resistance  to  these 
changes.  However,  incentives  to  foster  inter-professional  collaboration,  targeting  health 
professionals who recognise the importance of the initiative, are currently being discussed. 

To the best of our knowledge, there are no well-defined national investments and funding 
programmes  to  ensure  adequate  resources  for  sustainable  change  and  up-front  costs. 
Neither are there adequate funding mechanisms to ensure an equitable funding distribution 

6   Caisse Primaire d"Assurance Maladie 
7   Caisse d'Assurance Retraite et de la Santé Au Travail 

11 

 
                                              
for  different  services  or  levels  of  services.  The  different  stakeholders  could  perceive  this 
situation as an inhibitor of integrated care. 

2.4  Organisation, health professionals and patients 

MACVIA-LR  is  based  on  a  public-private  partnership  that  includes  all  health  professionals 
(e.g.  physicians,  pharmacists,  physiotherapists,  nurses,  others)  and  numerous  patients’ 
organisations. The following table shows the stakeholders involved: 

Table 2: MACVIA-LR stakeholders 

Acronym 

Organisation (French) 

Organisation (English) 

Region 

CR-LR 

Conseil Régional Languedoc-Roussillon 

UM1, UM2, UM3  Université Montpellier 1,2,3 
Unîmes 

Department 

City 

Teaching 
and 
research 
Teaching 
hospitals  
National or 
regional 
agencies 

ANR 
ARS 
CARSAT 

CNSA 

CPAM 
HAS 
INRS 

CCAS 

Conseil Général Hérault (34) 
Conseil Général Gard (30) 
Montpellier Agglomération 
Nîmes Agglomération 
Lattes 
Balaruc les Bains 
Juvignac 
Lodève 
Prades-le-Lez 

Université de Nîmes 
Ecole des Mines d’Alès 
CHRU Montpellier 
CHU Nîmes 
Agence Nationale de la Recherche 
Agence Régionale de Santé 
Caisse d'assurance retraite et de la 
santé au travail  
Caisse Nationale de Solidarité pour 
l’Autonomie 
Caisse Primaire d’Assurance Maladie 
Haute Autorité de Santé 
Institut National de Recherche et de 
Sécurité, pour la prévention des 
accidents du travail et des maladies 
professionnelles 
Centre d’Action Sociale 

Regional Council Languedoc-
Roussillon 
General Council Hérault state   
General Council Gard state   
Montpellier area  
Nîmes area  

University of Montpellier 1,2,3 
University of Nîmes 
Engineering school of Alès 
University hospital of Montpellier 
University hospital of Nîmes 
National Research Agency 
Regional Health Agency 
Retirement and occupational 
health insurance agency  
National Solidarity Fund 
for Autonomy 
Regional health insurance agency 
National Authority for Health 

Social and welfare community 
centre  

Source: Authors elaboration 

It  is  worth  noting  that  the  initiative  adopted  a  patient-centred  philosophy  that  strongly 
focuses  on  patients'  needs.  As  a  result,  45,000  patients  attend  the  Thermes  de  Balaruc 
every year and more than 1,000 patients and caregivers attend the L’Etape Living Lab.  

MACVIA-LR  has  been  initiated  in  different  areas  of  the  region  and  is  gradually  being 
deployed  in  the  entire  region  that  stretches  from  the  Provence-Alpes-Côte  d'Azur,  Rhône-
Alpes, Auvergne, Midi-Pyrénées on the one side, and Spain, Andorra and the Mediterranean 
Sea on the other side. Figure 3 depicts the main areas of implementation of the MACVIA-LR.  

12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 3: Areas of implementation of MACVIA-LR 

Source: Author’s elaboration. 

2.5 

Information and Communication Technologies 

The  IT  system  used  in  the  CHRU  Montpellier  to  develop  the  co-morbidity  clinic  has  been 
described  in  detail  by  Buorett  and  Bousquet  (2013).8 The  APS  uses  DXCare®,9 the  hospital 
information  system  used  by  all  members  of  the  Montpellier  hospital.  A  wide  variety  of 
information is managed with this system and IPSoins®, which carries out the data collection 
and record acquisition, stands out as regards the quality and diversity of the information it 
manages.  IPSoins®  provides  hospital  health  care  professionals  with  a  single  tool  that  can 
handle  letters,  administrative  information,  imaging  and  test  requests/results,  specialist 
medical  files,  oral  recordings,  databases,  and  more.  Within  the  framework  of  research 
undertaken in the area, innovative algorithms and statistical models are being developed, 
tested and released on to the market. The aim is to explore a large amount of data that is 
heterogeneous and diverse but can be combined in order to search for chronic diseases. As 
shown in its standard catalogue of services and products, IPSoins® aims to provide a large 
number  of  “career”  modules  including  medical,  surgical  and  psychiatric  specialities, 
obstetrics  and  follow-up  care.  In  case  more  data  is  needed,  or  specific  needs  are  not 
covered  by  the  standard  modules,  such  as  the  management  of  a  clinical  study,  an 
extension  module  using  questionnaires  is  available..  Constructed  with  the  help  of  ICT, 
IPSoins®  is  secure  and  readily  accessible  to  the  other  actors  involved  in  the  follow-up  of 
patients.  Through  telemedicine,  it  is  possible  for  private  health  care  professionals  (e.g. 
private  doctors  and  professionals  from  the  medico-social  sector)  to  access  parts  of  the 
medical  files  from  a  distance  when  following-up  on  patients.  Access  is  highly  secure  and 

8   Bourret R, Bousquet J. An integrated approach to telemonitoring noncommunicable diseases: best practice 

from the European innovation partnership on active and healthy ageing. World Hosp Health Serv. 
2013;49(3):25-8. 

9   MedaSys, and Orange business service, http://www.orange-business.com 

13 

 
 
                                              
already available to sites outside of the premises of the Teaching Hospital of Montpellier. A 
fine-tuned, specific and precise management mechanism allows administration of rights in 
compliance  with  the  statutory  and  legal  regulations  regarding  access  to  patient  data. 
IPSoins® is currently being deployed and will be evaluated in a city hospital in Sète. 

2.6  Governance 

The  MACVIA-LR  initiative  is  led  by  the  Fondation  des  Maladies  Chroniques  -  Languedoc-
Roussillon  MACVIA.  MACVIA-LR  needed  the  foundation,  which  was  identified  as  the  most 
appropriate for the task, to ensure a stable structure. The foundation abides by the rules of 
the  Fondations  Partenariales,10 the  founding  members  of  which  are  the  University 
Montpellier 1, the University hospitals of Montpellier and Nîmes and the Région Languedoc-
Roussillon.  The  Fondations  Partenariales  can  also  participate  in  international  cooperation 
frameworks. The MACVIA-LR governance includes founding members of the Fondation and 
the MACVIA-LR Executive Committee. 

Table 3: MACVIA-LR governance 

Name 

Organisation 

Coordinator 
Leadership 

Executive 
Committee 

Jean Bousquet 
Christian Bourquin  
Philippe Augé  
Philippe Domy  
Jean-Olivier Arnaud 
Jacques Bringer 
Nicolas Best   
Rodolphe Bourret   
Thierry Camuzat  
Jean-Emmanuel de la Coussaye   
Olivier Jonquet   
Jacques Mercier 
Jean-Marie Robine 

Project manager  Anna Bedbrook 

University Montpellier 1, University Hospital, Montpellier 
President, Région Languedoc-Roussillon 
President, University Montpellier 1 
Director General, University Hospital, Montpellier 
(former) Director General, University Hospital, Nîmes 
Dean, Medical School, Montpellier-Nîmes 
Deputy General Manager, University Hospital, Nîmes 
Deputy General Manager, University Hospital, Montpellier 
Deputy General Manager, Region Languedoc-Roussillon 
President, CME, University Hospital, Nîmes 
President, CME, University Hospital, Montpellier 
Vice president, University Montpellier 1 
Inserm 
University Hospital, Montpellier 

Source: Authors elaboration 

The  foundation  has  a  strongly  focused  and  diverse  governance  structure,  in  which  all 
stakeholders  are  represented.    This  promotes  coordination  across  the  different  health 
providers and levels of care, and includes a legal framework for liability issues.  

2.7  Organisational processes 

The MACVIA-LR organisational process has been designed as a Living Lab, which carries out 
the following activities:  (1) co-creation: co-design by users  and producers; (2)  exploration: 
discovering  emerging  usages,  behaviours  and  market  opportunities;  (3)  experimentation: 
implementing live scenarios within communities of users and (4) evaluation: assessment of 
concepts,  products  and  services  according  to  socio  ergonomic,  socio-cognitive  and  socio-
economic  criteria.  These  activities  have  been  undertaken  in  order  to  define  the  three 
interventions: AIRWAYS ICPs, ARIA and Co-morbidity clinics. 

10   (Article L. L719-13 du code de l’éducation http://www.universites-numeriques.fr) which follow the Code de 
l’Education (Law n°87-571 of 23 July 1987, Decree n°91-1005 of 30 September 1991 to apply Law 
n°90-559 of 4 July 1990 and modify Law n°87-571 of 23 July 1987). 

14 

 
 
                                              
The following figure depicts the clinical pathway for allergic disease followed by AIRWAYS 
ICPs  and  ARIA.  Specialists  within  the  hospitals  currently  use  this  pathway  to  assess  and 
regularly review the status of patients with allergic diseases. In addition, a group of primary 
care physicians has been included in a pilot to test how this instrument could be applied in 
primary  care  and  how  this  tool  can  facilitate  integration  between  the  different  tiers  of 
care.11 

Figure 4: Uniform approach to the severity of allergic diseases 

Source: Bousquet et al. (2012) 

In  the  case  of  the  co-morbidity  clinics,  the  list  of  evidence-based  criteria  included  in  the 
one-day  clinical  programme  was  developed  using  a  Delphi  process,  in  which  all  the 
professionals involved participated. This list includes the criteria for screening CVD, COPD or 
D2M  comorbidities,  the  prediction  of  their  exacerbations  and  the  overall  assessment  of 
severity,  and  a  risk  assessment.  The  process  is  initiated  by  a  primary  care  physician  who 
refers patients to the hospital. After a co-morbidity evaluation, the patient is followed up in 
primary care. This process is supported by the IPSoins® technology (see Section 2.5). 

11   Bousquet J, Mantzouranis E, Cruz AA, Ait-Khaled N, Baena-Cagnani CE, Bleecker ER, et al. Uniform 

definition of asthma severity, control, and exacerbations: document presented for the World Health 
Organization Consultation on Severe Asthma. J Allergy Clin Immunol. 2010;126(5):926-38. 

15 

 
 
 
 
 
 
 
                                              
Figure 5: Chronic disease clinic to assess co-morbidities 

Source: Bousquet et al3. 

2.8  Reimbursement model and economic flow 

The  individual  components  of  the  project  are  fully  funded  by  the  French  social  security 
system. However,  the  integration  of  MACVIA-LR  in  the  French  health  system  is  still  being 
discussed, so a full description of the reimbursement model and economic flow cannot be 
provided yet. 

3  Transferability  

The  group  in  Montpellier  has  wide  experience  in  transferability,  since  the  ARIA  Guidelines 
have  been  translated  into  52  languages  and  used  in  67  countries.  Moreover,  several 
governments in Europe and elsewhere have approved these guidelines. Jean Bousquet has 
been the chair of the Global Alliance against Chronic Diseases of the WHO for a period of 8 
years and has helped, together with the Ministers of Health, to deploy a GARD programme 
in  several  countries.12 In  this  regard,  it  is  important  to  note  that  transferability  is  only 
achieved if there is an appropriate legal framework approved by the Minister of Health  or 
the  relevant  authorities  in  each  country.  Once  such  a  legal  framework  is  developed, 
institutional and organisational barriers can be managed.  

In this regard, AIRWAYS ICPs has already been approved by 6 Commitments for Action, 13 
EIP on AHA Reference Sites, NHS England and Scotland, 6 national coordinations (Portugal, 
Poland,  Lithuania,  Czech  Republic,  Italy,  Turkey)  and  governments,  the  most  important 
chronic  respiratory  disease  patients'  association  in  Europe  (EFA),  as  well  as  by  major 
scientific societies (EAACI, ERS). It is a WHO GARD research demonstration project. Table 3 
provides a list of the members of the Airways ICPs.  

12   Yorgancioglu A, Cruz AA, Bousquet J, Khaltaev N, Mendis S, Chuchalin A, et al. The Global Alliance against 
Respiratory Diseases (GARD) Country Report. Primary care respiratory journal : journal of the General 
Practice Airways Group. 2014;23(1):98-101. 

16 

 
 
                                              
EIP  on  AHA  Commitment 
for action 

EIP on AHA reference sites 

EU regions 
National coordinations 

European 
patients’organisations 
European scientific 
societies 

WHO GARD 

ARIA 

Table 3: Members of AIRWAYS ICPs 

Organisation 

Région LR (France) 
FILHA (Finland) 
GARD Turkey 
Norway 
Portugal 
Warsaw region (Poland) 
Eurobiomed (France) 
Athens (Greece) 
Aura Andalucia (Spain) 
Basque Country (Spain) 
Campania (Italy) 
Coimbra (Portugal) 
Emilia Romania (Italy) 
North England (UK) 
Northern Ireland (UK) 
Polibienestar (Spain) 
Porto Age (Portugal) 
Scotland (UK) 
Southern Denmark (DK) 
Valencia (Spain) 
Wallonie (Belgium) 

Czech Republic 
Lithuania 
Romania 
Serbia 
Slovenia 
EFA (European Federation of Allergy and Airways 
Diseases patient’s association) 

Member 

J Bousquet, P Demoly 
T Haahtela, T Vasankari 
A Yorgancioglu 
KH Carlsen, KC Lodrup Carlsen 
C Barbara, E Melo Gomes 
B Samolinski 
C Royère 
T  Vontetsianos 

E de Manuel Keenoy 
G Iaccarino 
A Todo Bom 
A Addis 
N Wilson 
J Farrell 
F Rodenas 
J Fonseca 
G Crooks, D Henderson 
L Beck 
J Redon 
V Tellier 

V Kolek 
A Valiulis 
F Mihaltan, I Agache 
B Milenkovic 
M Zidarn 
S Palkonen 

EAACI (European Academy of Allergy and Clinical 

NG Papadopoulos 

Immunology 

ERS (European Respiratory Society) 
ERS (European Rhinology Society) 
EAP-UEMS (European Academy of Paediatrics) 
IPCRG  (International  Primary  Care  Respiratory 

E Bel 
WJ Fokkens 
A Valiulis 
NH Chavannes 

Group) 

Argentina 
Belgium 
Canada 
Cyprus 
France 
Germany 
Italy 
Japan 
UK 

N Khaltaev (Switzerland) 
AA Cruz (Brazil) 
CE Baena Cagnani 
C Bachert 
HJ Schunemann 
A Neou 
I Momas 
T Zuberbier 
GW Canonica 
K Ohta 
D Price, D Ryan 

17 

 
 
 
 
 
 
 
4  Conclusion 

The MACVIA-LR case has launched several initiatives as part of its activities as a reference 
site under the European Innovation Partnership on Active and Healthy Ageing built around 
chronic diseases, ageing and handicaps. The vision behind the MACVIA-LR initiative rests on 
the  prevention  and  management  of  chronic  diseases  as  an  essential  component  for  the 
promotion of active and healthy ageing, while achieving a reduction of chronic conditions. 
The main objective of MACVIA-LR is to develop innovative solutions for a network of Living 
Labs  in  order  to  improve  the  care  processes  for  patients  affected  by  chronic  disease 
conditions in the Languedoc-Roussillon area and to scale up the innovative solutions within 
this framework for the benefit of patients and health care actors. 

The  tree  main  initiatives  of  the  MACVIA-LR  deployed  in  the  Languedoc-Roussillon  region 
comprise  the  Integrated  Care  Pathways  for  Airway  Diseases  (AIRWAYS  ICPs),  Allergic 
Rhinitis and its Impact on Asthma (ARIA) and Co-morbidity Clinics. Despite the fact that the 
MACVIA-LR project targets the population in  the region in its entirety, the three  initiatives 
place particular emphasis on the prevention of unhealthy ageing among patients suffering 
from chronic conditions, including those with complex illnesses, by implementing a series of 
actions ranging from the early diagnosis and management of chronic respiratory diseases 
to the detection of un-recognised co-morbidities. 

The  MACVIA-LR  project  is  characterised  not  only  by  its  efforts  to  improve  care  processes 
through the integration of care services, but also by a strong political commitment. It was 
successful in engaging all stakeholders involved in the health care processes, ranging from 
public and private bodies to patients and policy makers. 

MACVIA-LR is an ambitious, but feasible project, which was drawn up under the leadership 
of  the  President  of  the  Languedoc-Roussillon  region.  It  is  expected  that  the  initiative  will 
reach  its  goal  of  reducing  avoidable  hospitalisations  for  chronic  diseases  by  20%,  while 
boosting the economic growth of the region and scaling up its activities to cover the entire 
country, the EU and other regions of the world. However, a major barrier to full exploitation 
of  the  approach  is  the  reimbursement  processes  that  are  still  subject  to  evaluation.  This 
could  potentially  hamper  wider  implementation  of  the  approach  given  the  potential 
resistance  from  stakeholders  involved,  despite  the  consensus  among  them  about  the 
urgent need to change the management of the health system for chronic diseases. Given 
the  novelty  of  the  approach  and  its  current  stage  of  deployment,  it  remains  to  be  seen 
whether full implementation can be achieved in the future and whether it can be applied to 
other contexts.  

Undoubtedly,  the  governance  mechanism  can  be  considered  as  the  main  facilitator  of 
integrated  care  in  the  MACVIA-LR  case.  The  Fondation  des  Maladies  Chroniques  - 
Languedoc-Roussillon has been established as the main tool to foster integrated care in the 
Region with the support of the Regional Government. The foundation brings together all the 
relevant  French  health  system  stakeholders  at  regional  level  and  thereby  facilitates  the 
diffusion of the innovation processes established. In addition, the foundation has  adopted 
the Living Lab methodology as a way of engaging health professionals and patients in the 
design  of  integrated  care  solutions,  and  it  considers  both  organisational  innovation  and 
technological  innovation.  Lastly,  incentives,  financing  mechanisms,  national  investments 
and  funding  programmes  could  be  perceived  as  barriers  that  must  be  overcome  if 
integrated care is to be fully deployed.  

18 

 
Figure 6: MACVIA-LR integrated care facilitators 

Source: Author’s elaboration. 

19 

 
 
 
References 

Chevreul  K,  Durand-Zaleski  I,  Bahrami  S,  Hernández-Quevedo  C  and  Mladovsky  P.  France: 
Health system review. Health Syst Transi, 2010; 12(6): 1–291. 

Bousquet  J,  Khaltaev  N,  Cruz  AA,  Denburg  J,  Fokkens  WJ,  Togias  A,  et  al.  Allergic  Rhinitis 
and  its  Impact  on  Asthma  (ARIA)  2008  update  (in  collaboration  with  the  World  Health 
Organization, GA(2)LEN and AllerGen). Allergy. 2008;63 Suppl 86:8-160. 

Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Allergic 
Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 
2010;126(3):466-76. 

Bousquet J, Schunemann HJ, Samolinski B, Demoly P, Baena-Cagnani CE, Bachert C, et al. 
Allergic  Rhinitis  and  its  Impact  on  Asthma  (ARIA):  achievements  in  10  years  and  future 
needs. J Allergy Clin Immunol. 2012;130(5):1049-62. 

Bousquet  J,  Anto  J,  Demoly  P,  Schunemann  H,  Togias  A,  Akdis  M,  et  al.  Severe  chronic 
allergic  (and  related)  diseases:  a  uniform  approach  –  a  MeDALL-GA2LEN-  ARIA  Position 
Paper. Int Arch Allergy Immunol. 2013;161(1):1-10. 

Bousquet  J,  Mantzouranis  E,  Cruz  AA,  Ait-Khaled  N,  Baena-Cagnani  CE,  Bleecker  ER,  et  al. 
Uniform definition of asthma severity, control, and exacerbations: document presented for 
the  World  Health  Organization  Consultation  on  Severe  Asthma.  J  Allergy  Clin  Immunol. 
2010;126(5):926-38. 

Bousquet J, Addis A, Adcock I, Agache I, Agusti A, Alonso A et al. Integrated care pathways 
for airway diseases (AIRWAYS-ICPs).European Innovation Partnership on Active and Healthy 
Ageing, Action Plan B3; Mechanisms of the Development of Allergy, WP 10; Global Alliance 
against Chronic Respiratory Diseases. Eur Respir J. 2014 Aug;44(2):304-23 

20 

 
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European Commission 
EUR 27150 EN – Joint Research Centre – Institute for Prospective Technological Studies 

Title:  Strategic  Intelligence  Monitor  on  Personal  Health  Systems  Phase  3  (SIMPHS3)  –  MACVIA-LR  (France)  Case  Study 
Report 

Authors: Jean Bousquet, Jacques Mercier, Antoine Avignon, Rodolphe Bourret and Thierry Camuzat 

Luxembourg: Publications Office of the European Union 
2015 – 20 pp. – 21.0 x 29.7 cm 

EUR – Scientific and Technical Research series – ISSN 1831-9424 (online) 
ISBN 978-92-79-46494-2 (PDF) 
doi:10.2791/107345 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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JRC Mission 

As the Commission’s  
in-house science service,  
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Working in close  
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Serving society  
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doi:10.2791/107345 
ISBN 978-92-79-46494-2