A small step towards P4P in France

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

Abstract

The National Health Insurance Fund offers a tri-annual contract to individual general practitioners with the aim of improving the quality of care for chronic diseases, encouraging prevention and cost-efficient prescriptions. Doctors will be paid on the basis of their results given a list of objectives set by the Health Insurance Fund. The contracts are signed on a voluntary basis with individual doctors and can provide up to 6000 Euros annually.

Purpose of health policy or idea

Since the beginning of 2009, the National Health Insurance Fund offers "contracts to improve individual practice" (CAPI, Contrats d'amélioration des pratiques individuelles) to individual general practitioners working as "soft" gatekeepers (médecin traitant) in order to improve their medical practice by providing financial incentives. The contracts set common objectives to health care professionals with respect to treatment and prescription patterns to be achieved over three years. These objectives are based on the recommendations of the High Health Authority (HAS), the National Institution for Health Products (AFSAPS) and the results of international comparisons. 

Doctors who sign the contract accept to improve the prevention rates among their patients, respect some treatment guidelines and increase generic prescription. On the side of the health insurance fund, it promises to provide the data required to monitor changes in their practice. Remuneration given to doctors will depend on their results in terms of prescription and treatment. Those who do not fully achieve the objectives set will be paid according to the progress made. The remuneration scheme is rather complex, but it is announced that the maximum amount earned could be near 6000 Euros a year, which makes an extra month of salary for the average GP.

Main points

Main objectives

The objectives set in the contracts are inspired by global public health objectives fixed by the parliament and currently cover three domains:

1. Improving prevention: the objective is to achieve 75% vaccination rate for over 65 years old patients, and 80 % breast cancer screening for woman aged 50 to 74 years old. It is also aimed to prevent the use of contraindicated drug combinations which can result in adverse reactions. The objective is to reduce the prescription of vasodilatators (which are overly prescribed despite being proven ineffective) and benzodiazepine (potentially dangerous and addictive) for elderly patients (65 and over).
2. Consolidation of quality of care for patients with chronic diseases: this mainly concerns diabetic patients and the objectives are to improve the proportion who are treated in line with current recommendations (eye exams, HbA1c prescription, etc). In addition, there is a results-based objective for treating high blood pressure: the target is to normalise blood pressure for 50% of the patients over three years.
3. Last, but not least, the contract also aims to "optimise" the prescription practices. There are seven groups of medication (antibiotics, anti-depressors …) for which "generic prescription" is encouraged with varying final targets.

The health insurance fund is planning to extent the contracts in the future to cover other public health priorities such as improving the rate of treatment in line with guidelines concerning moderate/severe depression and detection of osteoporosis.

Type of incentives

Financial: The payment does not replace any other payment made (fee-for-service and a small capitation payment already given to treat chronically ill patients) but adds on to it. And there is no cost for the GPs who do not achieve the objectives. 

The Health Insurance Fund claims that the cost of these contracts would be neutral. It estimates that the economies which will result from better generic prescription will cover the total cost of the contracts. 

Groups affected

Health insurance funds, general practitioners, patients

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

The wide variation in medical practice in terms of prescription and treatment patterns is a real problem for quality and efficiency of care in France. 

The CAPI contracts proposed by the Health Insurance Fund are not as drastic as the alternative solution which would be to replace the current fee-for-service for generalists with a capitation-type system to assure a more integrated approach to all health-care provided to patients. 

However, they can play a role for making generalists more aware of their responsibilities in terms of prevention and respecting guidelines. This is also a small step opening a hole in the tradition of collective conventions where individual generalists are not used to be accountable for their actions.

Political and economic background

France introduced a soft gatekeeping model in 2005 giving general practitioners new responsibilities in terms of better care coordination and prevention. 

Except for a small per capita payment for chronically ill patients, there are no financial changes in the way doctors are paid. But in the national collective convention setting the fees for doctor services, the generalists have promised to improve their treatment patterns in particular with better respect to clinical recommendations, more attention to prevention and coordination of care. After three years, and despite a high rate of participation in gatekeeping program, the reform did not achieve what was expected. There was little visible change in prescription, treatment and consumption patterns which deemed inefficient.

Clinical recommendations are not respected by the majority, the rate of generic prescriptions (which was already one of the lowest in Europe) decreased between 2006 and 2007 and prevention rates stayed very low. 

A study of the Commonwealth Fund, supported by the National Health Insurance Fund for salaried workers, showed that France compares very poorly with other developed countries for example in terms of prevention of diabetes.  Moreover, the National Health Insurance Fund has pointed out that there are wide variations in prescription and treatment patterns between doctors.

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

Disappointed by the results of the collective negotiations with general practitioners to improve medical practice and under pressure from the government to reduce the growing deficit, the National Union of Health Insurance Funds proposed to medical unions to introduce individual contracts.

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Kostenträger

• Patienten, Verbraucher

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

All of the numerous unions of generalists are against these contracts with different degrees of opposition and different arguments. The Federation of Medical Unions has expressed their reticence against the individual aspect of the contracts and their wish to continue collective bargaining on all of the issues concerning quality and continuity of care in exchange for an increase in the basic fee for GP consultations. 

The major left-wing union of generalists, while not completely against the objectives of the contract, expressed their concern that this type of contract (results-based) might encourage patient selection which already exists with a fee-for service system. Doctors will have less incentive to work in low-income zones where health outcomes are notably worse.  The unions also have reservations about the quality of data provided by Health Insurance Funds and the recommendations used to set the objectives. They claim that the objectives set are unrealistic, the administrative cost would be too high and in any case the bonus would not be high enough.

The right wing union is totally opposed to the principle of controlling "medical practice" or "freedom of prescription" implied by these contracts. They have called on their members to refuse to sign the contracts. 

There was not much reaction from patient associations or the media since the current debate on health reforms is monopolised by the discussions of the draft law for restructuring health care provision (see, HPM 2008/12, New regional health governance).

Actors and positions

Regierung
Government	sehr unterstützend		stark dagegen
Leistungserbringer
Unions of Generalists	sehr unterstützend		stark dagegen
Kostenträger
National Health Insurance Fund	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patient Associations	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The model contract was prepared by the Health Insurance Fund as an amendment to the national convention setting tariffs and regulating the relations between medical practitioners and the Health Insurance Fund (Article L.162-12-21 of Social Security code).  

The draft law for financing Social Security in November 2008 (Article 30) has introduced these contracts (CAPI) as an experimentation of new modes of financing doctors.

The contracts are officialised by a decree which has been published on 21 April 2009.

Legislative outcome

success

Actors and influence

Regierung
Government	sehr groß		kein
Leistungserbringer
Unions of Generalists	sehr groß		kein
Kostenträger
National Health Insurance Fund	sehr groß		kein
Patienten, Verbraucher
Patient Associations	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The first contracts will be signed in May 2009.

The Health Insurance Fund aims to convince quickly 10% of generalists (about 5000) to sign a contract in 2009. However, given the reactions from different unions, it is not certain that this will be achieved.

Monitoring and evaluation

 

Results of evaluation

 

Expected outcome

The impact of this policy will depend on the rate of participation in these contracts. For the moment there is no reason to be too optimistic, but some experts claim that the unions may have little impact on doctors' decisions. 

In any case, in the short term the impact will be marginal since not all the doctors are concerned by these contracts. Nevertheless, if the political will remains firm, and the Health Insurance Fund extends the content of these contracts, it is not impossible that the contracts become generalised. 

While some of the points made by the unions, especially concerning patient selection, can be a real issue, and should be followed carefully, overall the policy could contribute to improve the prescription patterns and prevention by generalists.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

 

References

Sources of Information

Le contrat d'amélioration des pratiques individuelles : un élément d'une stratégie d'efficience, Aubert J-M, Polton D, CNAMTS, March 2009

On line : www.ces-asso.org/docs/Actu_mars_2009/CNAMTS.pdf 

CAPI, Contrat d'amélioration des pratiques individuelles, in Lettre d information aux médecins, 31 Mars-Avril 2009

www.ameli.fr/fileadmin/user_upload/documents/090331_LIM31_ameli.pdf

Author/s and/or contributors to this survey

Or, Zeynep

 

Empfohlene Zitierweise für diesen Online-Artikel:

Or, Zeynep. "A small step towards P4P in France". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/fr/a13/2