Reorganization of health insurance governance
- Country:
- Frankreich
- Partner Institute:
- Institut de Recherche et Documentation en Economie de la Santé (IRDES), Paris
- Survey no:
- (2)2003
- Author(s):
- Agnès Couffinhal, Michel Grignon (CREDES)
- Health Policy Issues:
- Qualitätsverbesserung, Vergütung
- Reform formerly reported in:
Provider-Payer Contractual Reorganization
Current Process Stages
| Idee | Pilotprojekt | Strategiepapier | Gesetzgebung | Umsetzung | Evaluation | Veränderung/Richtungswechsel | ||
|---|---|---|---|---|---|---|---|---|
| Implemented in this survey? |  |
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Abstract
The reorganization of the relationship between self-employed health professionals and insurance funds has reached a stand-still. With trying the implement the reform, specialists entered into a conflict with the funds. In September 2003, a minimal agreement was enforced for them. However, the coming debates about a global reform of the health insurance schedule in 2004-2005 have sapped many actors' interest in the reform.
Purpose of health policy or idea
The ambition of this reform is to reorganize the relationship between health professionals and health insurance funds within a new contractual framework that enables them to:
- improve the coordination between self-employed professionals,
- negotiate targeted agreements for curbing health expenditure for each profession,
- promote good practices.
These objectives are to be achieved by a three-tier contract (see previous round for further details):
- On the first level is the Interprofessional Framework Agreement (Accord Cadre Interprofessionnel, ACIP) which should be jointly signed by the National Interprofessional Union (Centre National des Professions de Santé) and the public health insurance funds.
- Level two is a series of National Agreements (Conventions) between each profession and the health insurance funds that include AcBUS (Targeted Agreements on Best Practices).
- Within these National Agreements, two types of options can be open to individual health professionals who wish to join them on a voluntary basis (Professional Practice Contracts PPC that focus on the improvement of the individual's practice or Public Health Contracts PHC that focus on public health objectives or on the coordination between professionals).
Fee increases and / or additional lump-sum payments have been granted to most health professionals in the negotiations, but specialists unions broke away from the process and undermined the overall project. A form of status quo was reached with them in September 2003 but the reform is now lacking support and discussions about the future of the overall health insurance system will most likely be the main focus of health policy in the next few months.
Suchhilfe
Characteristics of this policy
Political and economic background
Partly as a result of the fee increases granted to health professionals during the negotiations of the contractual framework reform, public health expenditure increased by 7.2% in 2002 (the
parliament had voted an objective of +4%). In 2002, the health insurance deficit increased to 6 b. € and is expected to reach 11 b. € in 2003. Reinforced by criticisms about France's lack
of commitment to complying with the "stability and growth" agreement underpinning the euro currency, concern about the issue of social deficits is growing.
Soon after he came in power to 2002, the Prime Minister announced that he would undertake reforms of the national pension and the health insurance systems. The former generated a lot of social unrest
in the first half of 2002, and the government decided to postpone the health insurance reform for a year. Nevertheless, the topic is becoming increasingly central to the debates about the health care
system. All in all, the semi-failure of the reform discussed here is seen either as a consequence of a shift in the focus of the political debate or as further proof that the old system is no longer
viable.
Another contextual element that probably limited the physicians' motivation to support this reform early on and led them to waver at the end, is the fact that a new fee schedule should apply to them
in July 2004. This schedule will be based on the medical value of the rendered service and its implementation is already expected to be controversial.
Purpose and process analysis
Current Process Stages
| Idee | Pilotprojekt | Strategiepapier | Gesetzgebung | Umsetzung | Evaluation | Veränderung/Richtungswechsel | ||
|---|---|---|---|---|---|---|---|---|
| Implemented in this survey? | |
|
|
|
|
|
|
|
Stakeholder positions
As the previous report on this reform pointed out, physicians resisted it from the start. MG-France, a generalists' union whose representativity has waned in recent years, is the sole union to
have signed the National Agreements' amendments for generalists in 2002 and 2003.
In January 2003, a memorandum of understanding was signed by a larger number of unions and it was decided that a National Agreement for physicians would be drafted by March.
Negotiations failed and all unions except for MG-France put an end to discussions with the funds in April 2003 and demanded that a Minimal Contractual Agreement be drafted. This type of Agreement
(Règlement Conventionnel Minimal) is enforced by the government when no National Agreement is signed between the funds and a specific health profession. It sets the fee levels and
allows patients to be reimbursed on that basis. So, in essence, the specialists' unions asked for government intervention in the process.
Meanwhile, the ACIP negotiations were suspended and never resumed. Specialists in some parts of France threatened to abandon the Agreement altogether (in that case social security bases it's
reimbursement to the patient on a discretionary low fee of about 1€). Although no figures are available, it seems that a minority of physicians did carry that threat through for a few weeks.
Other specialists (among those who are not allowed to balance-bill all the time), encouraged by the unions, made massive use of their right to bill "one-time extra-charges". These
Dépassements exceptionnels can only be charged, as an exception, to a previously informed patient if he/she has demands that go beyond the usual standards. This resulted in conflicts
between specialists and local health insurance funds that were trying to sanction them.
At the end of the summer 2003, the government demanded that the funds and unions jointly draft a Minimal Agreement. The text was published on September 22nd and will be valid until December 2004.
This Minimal Agreement raises the fee for a specialist visit from 23€ to 25€ and grants specialists a few of other financial advantages. In return, specialists committed themselves to
signing a series of Targeted Agreements on Best Practices, Professional Practice Contracts and Public Health Contracts.
Influences in policy making and legislation
The following table shows that between March 2002 and September 2003 (the end of this survey period), more than 30 formal agreements were reached. All health professions signed at least one type
of agreement with the funds. The new GPs (or rather MG-France) seem to be the most active participants in the process but the actual take-up rates for the individual agreements and the outcomes are
not known yet.
Health
Profession AcBUS
CBP -CPP CSP
GPs 4 national/3
regional
2 1
Radiologists 1
Pediatricians
1 1
Specialists
1 1
Dentists 1
1
Mid-Wives
1
1
Physical
Therapists 1 1
Nurses
1
1
Speech Therapists
1
1 1
Orthoptists 1
1
Directors of
laboratories 1
1
Transport Services
1
1 1
Adoption and implementation
- The implementation is still under way. In particular, it is unclear at this stage whether the specialists will continue their protests for the unions that signed the draft Minimal Agreements have been heavily criticized. Still, it can be hoped that the financial concessions that were made will temporarily ease the tensions.
- Whether the new framework will be fully implemented or has now become a empty shell is unclear. The Interprofessional Agreement (ACIP) has not been discussed for months and even if specialists are now formally integrated in the general framework, it is unlikely that they would be willing to participate in negotiations on this subject.
- The funds appear committed to proposing more agreements (AcBUS or individual optional contracts), but the focus of the policy debate is clearly elsewhere and many involved actors seem disillusioned.
Monitoring and evaluation
No systematic evaluation of this policy has been undertaken and little information is available (for instance, no figure has been published about the number of professionals that chose to sign the
individual contracts).
Still, in June 2003, one year after the amendment to the GPs' National Agreement was signed that included the AcBUS on home visits and one on streptotests - see previous report -, a series of
articles and press releases provided some elements:
The use of streptotests has increased (the impact on antibiotics prescription is not known).
It appears that the number of house calls decreased by 20% (the trend was already decreasing before) and the total volume of GP visits decreased very slightly.
It is not clear which share of the increase in generic sales can be attributed to GPs' efforts to prescribe them.
The funds declared that they were satisfied with these results. The Minister and the funds had promised that the increase in GP remuneration would be financed by the savings on drugs. They show data
that confirms this statement, but the figures are disputed by the Public Accounting Office.
Furthermore, in its yearly report on social security published in September 2003, the Office acknowledges that some targeted agreements are "interesting", but its overall assessment of the
contractual framework is rather pessimistic. It argues that the surge of the deficit can be largely attributed to the fee increases granted in the process. It doubts that the funds can evaluate the
AcBUS's impact and impose sanctions if the targets are not met. More generally, the report criticizes the lack of regulatory framework for public health expenditure.
Expected outcome
References
Sources of Information
National health insurance fund's website (health professionals section):
http://www.ameli.fr/2/RUB/2/homeb.html
The main physician unions that opposed the reform:
http://www.csmf.org/ (Confédération des Syndicats Médicaux Français)
http://www.gie-sml.fr/default.htm (Syndicat des Médecins Libéraux)
A physician union that supports the project (minority):
http://www.medsyn.fr/mgfrance (Fédération Française des Médecins Généralistes)
The Public Accounting Office Report on Social Security (Rapport annuel au parlement sur la sécurité sociale, Cour des comptes, septembre 2003): http://www.ccomptes.fr.
Reform formerly reported in
| Provider-Payer Contractual Reorganization Process Stages: Pilotprojekt |
Author/s and/or contributors to this survey
Agnès Couffinhal, Michel Grignon (CREDES)