|Implemented in this survey?|
This policy aims at improving the coordination and organization of the access and process of care for patient by introducing several financial incentives for them to accept: a gatekeeping primary care system plus a referral system for access to secondary care, and an electronic personal medical record medical for the management of care.
This policy seeks to improve the coordination and organization of the process of care for a patient and is part of the more general reform law passed in August 2004. To achieve that, it introduces several financial incentives for patients to accept a more organized access to care and some restrictions to his freedom of choice:
Improvement of the coordination of health care.
Financial incentives through coinsurance and copayment.
Patients, Physicians (specialist and general practionner), Voluntary Health Insurers depending on theirs reimbursement policy
|Medienpräsenz||sehr gering||sehr hoch|
There has been a frequent rhetoric on the lack of coordination of health care services, attributed to the fact that there is no gatekeeper and that patients are free to access any specialised care
by various ways (hospital outpatient department, emergency rooms but also through very dense supply of specialist in private practice.
The general idea is that this lack of coordination generates both quality problems (e.g. physician ignoring the prescription of each other, lack of follow up after hospitalisation, insufficient management of patients with chronic disease) and inefficiencies (e.g. duplication of procedures, patient shopping around…).
A previous reform (1996) opened up the possibility of experimenting with different forms of provider networks at the local level. The aim of the experiment was to try out new forms of coordination between professionals providing ambulatory care or between ambulatory care and hospital care.
In 1998 the "referring doctor scheme" was introduced. Every general practitioner can become a referring doctor for any patient willing to participate in the referral system. They are paid an extra fee to ensure the coordination and continuity of care for their patients. Patients who have accepted this gatekeeping scheme do not have to pay the physician visit in advance (and ask for reimbursement afterwards), they only pay the copayment. So far 12% of general practitioners and 1% of the population have been enrolled in this scheme.
|Implemented in this survey?|
The usual doctor scheme may be viewed as an extension of the concept of referring doctor, but it is now compulsory.
The approach of the idea is described as:
This policy tries to avoid direct conflict between GPs and specialists (unlike the referring doctor scheme, which was clearly rejected by the specialists and divided the GP population).
First, it allows specialists to take the role of usual physician. Moreover, it satisfies a longstanding demand of specialists to open up the possibility of billing additional fees. This possibility is currently limited to one third of specialists.
There is a global consensus, even among patients organisations, about the interest of a better organisation of medical care consumption to enhance quality of care.
|Government||sehr unterstützend||stark dagegen|
|Parliament||sehr unterstützend||stark dagegen|
|Payers||sehr unterstützend||stark dagegen|
There will be probably an evaluation process of the usual doctor scheme, led by the sickness funds.
The expected outcomes are, as seen before, better quality of care and cost containment. The idea that a better coordination is worthy in terms of both quality and efficiency is very popular, but
it is not clearly evidence-based. As far as the potential for cost savings is concerned, the amount of the so-called "duplication of diagnosis and treatment procedures" or "shopping around
behaviours" has never been really assessed. Yet the figures put forward by the Ministry are very high (around 10 billions € per year from 2007 on).
The savings expected with the personal medical record may also be offset, in the short run, by the cost of the implementation of the system (current estimates are between 0,65 and 1,2 billion € per year for the three first years).
Besides, a lot of experts think that the deadline announced for implementation of this electronic personal medical record (2007) is far too optimistic.
There is also a perverse incentive built in the system, since specialists will be better paid for patients who do not follow the rule of being referred (which is considered as the "right" behaviour). The extent to which it might lead some specialists to favour the access for these patients is under debate (it could mimic the current situation in some departments of public hospitals, where the physicians may see patients in private practice, with much quicker appointments, and sometimes better consideration, than when the see them in the public sector). It may thus create some inequity in access to care (although the rhetoric is that the referral system ensures the right level and quality of care).
In that respect, the balance between raising the coinsurance rate or allowing extra billing by specialists will be very important. A very liberal system, where specialists would set their own fees (which part of them demand) may jeopardize the access to care.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
Dominique Polton and Julien Mousquès