Evaluation of professionals' practice

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The evaluation of professionals? practices (EPP) is a form of medical audit. It aims to improve the quality of care by giving to doctors a peer?s feed back on their patterns of practice. It was first set up by law in December 1999 as a voluntary process for doctors working on a private practice in the ambulatory care sector. The health insurance reforms of august 2004 was a major turn in the development of EPP. It made it compulsory to every doctors.

Purpose of health policy or idea

The main purpose of the policy is to improve quality, safety and efficiency of curative as well as preventive health care by giving to doctors a peer's feed back on their patterns of practice. It aims to reduce medical practice variations that in France, as in many countries, are seen as a niche for losses in the health care system: loss of money - by not using the most efficient way of managing diseases and patients doctors are wasting money; loss in quality of care - by not using the best therapeutic procedures when doctors do not offer the best quality of care to patients who obviously do not have equitable access to care of good quality; thus, in addition, loss in equity.

It is compulsory for every doctor whatever his conditions of work is (ambulatory or hospital sector, public or private practice) to go through EPP. When doctors are not complying with this policy they will not be  allowed anymore to practice. When doctors have validated the EPP they will have a certificate that they can use as a label of quality.

Main points

Main objectives

EPP is a form of medical audit. It aims to improve the quality of care by giving a peer's feed back to doctors on their patterns of practice.

It was set up by law in December 1999 (Decree n°99-1130 of the 28th of December 1999). It was to be organized in common by the national agency for medical evaluation (ANAES) and the regional associations of self-employed doctors (URMLs).

Voluntary assessments of quality of practice were offered for free to every self-employed generalist as well as specialist doctor in the ambulatory care sector.

Two categories were defined: collective assessment and individual assessment. The principle is the same for both: doctors are helped in the evaluation of their own practice by other doctors that have received a special training from the ANAES. Special tools made by the ANAES are used to compare doctors' observed practice to recommended practice through the guidelines elaborated or certified by the ANAES or the French agency for health care product safety (AFSSAPS). "Evaluated doctors" receive a written feedback from "evaluator doctors" with advice on how to improve their practices. This remains confidential between the two doctors. There is no reporting to any institution.

The URMLs were in charge of organizing the EPP at the regional level. They should publicize the process, pay for the services of "evaluator doctors" certified by the ANAES and run an annual evaluation.

In 2003, four regions entered the process on an experimental basis. Every self-employed doctor in the region received a letter explaining the EPP and offering him to participate.

From January 2004, the EPP implementation has been extended to the whole national territory. At that time some barriers to this development had appeared. Evaluator doctors are paid for evaluating their colleagues on the URMLs' own budget. However, there is a great diversity in the URMLs' wealth in France. Indeed, they are funded by a specific contribution from physicians. Therefore, their budget is highly dependant on the number of doctors in the region that varies a lot throughout the national territory.

A new turn in the development of EPP was due to the reform of the health insurance fund in august 2004. EPP was made mandatory to every doctor including private and public hospital doctors. It was also recognized as an action of continuing medical training.

The organisation of the policy was defined in a decree voted on the 15th of April 2005. It specified that every doctor should have gone through the EPP process by 2010 otherwise sanctions will be applied.

One of the main change in the organisation is that the evaluation can not only be run by "evaluator doctors" but also by an independent body appointed by the High Authority on Health (Haute Autorité de Santé-HAS) that has replaced ANAES.

Apart from that, for the case of the ambulatory care sector, the organisation remains the same. For the case of private hospitals doctors, URMLs and the hospital medical confederation are jointly responsible. For the case of public hospital doctors, hospital should organise the EPP for their doctors following the recommendation of HAS.

To go through the EPP process can include several audit sessions on a 5 year period. A regional commission depending on the medical association regional committee will validate the EPP and the local council of medical association will deliver a certificate or will apply sanctions.

Type of incentives

When doctors are not complying with this policy they will not be allowed anymore to practice. When doctors have validated the EPP they will have a certificate that they can use as a proof of quality.

Groups affected

medical doctors

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

In France contemporarily to a strictly accounting concept of cost containment, a new paradigm called the "medical based cost containment" was developed since the late 80's. From then, in order to put this concept into practice many measures were implemented.

Change based on an overall national health policy statement

medical based cost containment concept

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

As part of the "medical based cost containment" concept, following an increasing emphasis on medical continuing training, the evaluation of professionals' practices (EPP) was developed from the 1999. It is a form of medical audit. It aims to improve the quality of care by giving to doctors a peer's feed back on their patterns of practice.

For approximately a decade, there has been an increasing development of the evaluation of medical practices in the ambulatory care sector. International medical audit experiments have influenced such an evolution. The national agency for medical evaluation (ANDEM) and later the national agency for accreditation and medical evaluation (ANAES) have encouraged the formation of medical audit groups. Many doctors entered in the process of medical audit on a voluntary basis. Moreover, since 1994, medical audit are included in the missions devolved to the regional associations of self-employed doctors: URMLs.

In 2003, four regions entered the process on an experimental basis. Every self-employed doctor in the region received a letter explaining the EPP and offering him to participate.

The first evaluation of EPP was done in September 2003. It was mainly related to the doctors' satisfaction and perception of the impact of this category of medical audit on their practices. At that time, in the 4 regions one hundred and thirty five doctors had gone through the EPP. They were broadly satisfied, and found the EPP beneficial to the improvement of the quality of their practices. However, when from January 2004 the EPP implementation has been extended to the whole national territory many doctors perceived the EPP as a first step for reinforcing control on their practice, therefore they were reluctant to enter in the process. This tends to show that in that time context of difficult relationship with the government and the NHI funds, French doctors, at first, did not perceive the EPP as a beneficial activity increasing the quality of their practice, but as an administrative task requesting time that should be paid for.

Therefore, medical audit is not a new concept in France. What is new is the way of making it compulsory from July 2005.

This last development is linked to the reluctance of many doctors to enter the process and the governments will to develop it. By making it compulsory, the government had to reach a consensus on its organization with medical doctors trade union, the medical doctors association as well as the confederation of head representatives of the URMLs. It currently appears that doctors seem to be more confident that the aim of the EPP is not to control their practice but to help them. As a matter of fact, many URMLs that were primarily reluctant to enter in the process, have already started to publicize it and many doctors working in private hospital are ready to enter in the process.

Initiators of idea/main actors

• Regierung

Approach of idea

The approach of the idea is described as:
amended: 14th of April decree n°2005-346

Innovation or pilot project

Stakeholder positions

It appears that the negotiation that took place to set up the organization of EPP, as it is done in the 15th of April decree, was a long and difficult process as every stakeholder defended their prerogatives. However, the current pattern seems to be consensual.

Actors and positions

Regierung
MoH	sehr unterstützend		stark dagegen
medical associations	sehr unterstützend		stark dagegen
confederation of URMLs	sehr unterstützend		stark dagegen

Influences in policy making and legislation

This is already a formal piece of legislation: 14th of April decree n°2005-346

Legislative outcome

success

Actors and influence

Regierung
MoH	sehr groß		kein
medical associations	sehr groß		kein
confederation of URMLs	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The redefined EPP should start from the 1rst of july 2005. The HAS is the main actor of the implementation process. It trains the "evaluator doctors", appoint the independent body that can run EPP, and make the tools that are used to compare doctors' observed practice to practice recommended.

Its seems that doctors and the URMLs (that are responsible for the EPP for private doctors) are not reluctant to enter the process.

What is striking is that URMLs remain responsible for the organisation of the EPP for doctors working on a private basis and that they will extend the number of doctors going through the process. Therefore, it increases dramatically the financing problem that was previously a barrier to the development of EPP because most of the URMLs' budget were not high enougth to pay for the "evaluator doctors". However, the decree remains silent on how to solve this.

When a doctor has gone through the EPP process this should be validated by the medical association regional committee and the local council of medical association should deliver a certificate or apply sanctions. However, It has to be noted that the local council, decided by law in 2002, hasn't been put in place yet.

One can wonder, if these two last facts won't block the developpment of EPP as it has already happened for the case of Continuing Medical Education. Further on, the involvment of policy makers in the development of policies aiming to improve the quality of care can be called into question.

Monitoring and evaluation

no

Expected outcome

The expected outcome is to improve the quality of care.

Impact of this policy

Gerechtigkeit

System weniger gerecht

System gerechter

References

Sources of Information

14th of April decree n°2005-346

http://www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=SANS0521125D

Author/s and/or contributors to this survey

karine chevreul

Empfohlene Zitierweise für diesen Online-Artikel:

karine chevreul. "Evaluation of professionals' practice". Health Policy Monitor, May 2005. Available at http://www.hpm.org/survey/fr/a5/5