Update on new regional health governance

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The Minister of Health, Mme. Bachelot, presented last year a major reform package which would transform radically the organisation and the governance structure of health care provision in France. After months of parliamentary debate, followed by back-and-forth discussions in the Senate the law was finally passed in July 2009. The legislative process and principal changes to the reform since it was originally proposed are presented.

Neue Entwicklungen

The initial draft consisted of 91 pages and 33 articles - it reached 180 pages and 148 articles at the end with more than 400 amendments after six months of parliamentary debate. The version voted on by the parliament (in March) was substantially altered in the different commissions in the Senate, before finally getting back to something close to initial form (in June).

 The initial reform package to improve the supply and coordination of health care at the regional level consisted of four major chapters. Below, the key amendments to the measures as originally proposed are summarised.

1. More regional governance 

The key measure proposed in draft law was the creation of new "Regional Health Authorities" (Agences Régional de Santé, ARS) which would bring together, along the lines of a "one-stop-shop", seven public instances which are currently in charge of healthcare policy at the regional and departmental level.

Despite the large number of amendments deposed, the final text is close to the initial version. Indeed, the amendments adapted have reinforced the central role of the ARS, by asserting their responsibility for reducing health inequalities, ensuring that healthcare provision matches/corresponds the need of the population, and respecting national health expenditure objectives, and in improving the articulation between health and social services with better coordination of ambulatory, hospital and long-term care.

Nevertheless, the power given to these new agencies and to their directors was a major subject of dispute between the social insurance funds and the State. Several amendments were made to limit their power to "execution of nationally defined policies" instead of them being the main actors in defining regional policies. These amendments, introduced initially by the Social Affairs Commission of the Senate, were rejected in the final vote in the Parliament. Instead, adjustments are made to better frame the responsibilities of the directors of these agencies and mechanisms of accountability. Moreover, it was decided that the directors will not necessarily be high-level civil servants (préfet) but could be any qualified person.  But The Ministry of Health has kept the authority to appoint these directors.

2. Modernising the organisation of healthcare institutions

The second significant structural change proposed was the creation of new legal entities called "local hospital communities" (communités hospitalières de territories, CHT) by regrouping a range of small and big hospitals on the basis of complementarity of competencies. The rules of hospital governance were also modified to give hospital directors more autonomy and flexibility in management to improve efficiency.

While the creation of the CHT was not a particular problem in the parliamentary discussions (after the promises made by the Minister that there would not be any hospital closure), the proposed changes in the rules of management in public hospitals became a serious subject of conflict between the government and health care professionals.

The law introduced a board of management (replacing the executive council) and a board of surveillance (replacing the administrative council). Hospital directors, who are now supposed to act more like managers, will still be nominated by the cabinet. The amendments proposed and the discussions in both houses of the parliament were around the composition of each of these boards and their respective power. The medical profession, with demonstrations in the street and strikes in some hospitals, claimed that the medical logic in hospitals will be abandoned for "efficiency" and public hospitals are in danger.They fought for more power in both instances.

The final version of the law states that the management council will mostly consist of doctors, and each hospital director (initially presented as managers) is obliged to have a double formation in both management and in medicine. The position of the board of surveillance (consists of locally elected representatives, doctors and qualified persons and patients) has also been strengthened a bit to create a counter power to the director. But the government made a last minute adjustment to shift the power balance again toward the directors.

The law also changes the mode of nominating doctors in public hospitals (the final decision will be made by the director from a list proposed by the medical council) and introduces more flexibility in recruitment with a possibility of part-time contracts with private practitioners.

Moreover, private-for-profit institutions are given the possibility to take "public missions" such as emergency care and could be paid like public hospitals. This is claimed to be anti-constitutional by the socialists (putting in danger public service) and has been taken to high court. But the court rejected the claims and approved the law.

Given these changes in the role of the private sector, an amendment was made by the parliament to control the level of fees charged to patients in private clinics. Currently, most physicians working in private clinics charge higher fees (Sector 2), but the reimbursement to patients by public health insurance is made on the basis of a negotiated fee. Several recent reports have deplored the increasing cost of extra billings, particularly from surgeons. This is particularly problematic in areas where more than 70% of surgery is provided by private sector. However this amendment was dropped by the Senate (under pressure from surgeons).

3. Improving territorial access and care quality

The reform had also the ambition to redefine the organisation of ambulatory care and tackled the issue of unequal geographical distribution of physicians which has been a chronic problem over several years due to the sacrosanct principle of "freedom of installation" for physicians.

The amendments voted in the parliament included:

• Financial sanctions for physicians who refuse to serve at least partly in under-served areas (low doctor density);
• Authorization of the use of "testing" which would help to identify those physicians who refuse to serve the patients with CMU coverage (no possibility of extra billing for these patients with low income). Several surveys showed that this is a real problem in some areas and for certain specialties (a survey carried by IRDES suggests that more than 40% of gynaecologists and 30% of ophthalmologists refuse to accept CMU patients in Paris);
• Possibility for the pharmacists to prescribe contraceptive pills to women under the age of 35 years (for three months).

 All of these measures were dropped in the Social Affairs Committee of the Senate. However, the final version of the law voted in the plenary session re-introduced financial sanctions for physicians who refuse to serve at least partly in under-served areas. There will be an obligatory "health solidarity contract" (from 2013 onwards) for ambulatory-care physicians in high density areas to work partly in under-served areas in their region or pay a fine (maximum 3000€ a year).  

The ARS are also effectively given financial power to shape and improve care provision in the ambulatory sector. They will be able to sign contracts with physicians (at the regional level) for encouraging group practice, improving after-hour care or to reach specific quality objectives. To improve continuity of care, doctors will have to inform the regional/departmental medical council of their vacations or absence.  

 4. Improving preventive policy

The draft law comprised a chapter on improving prevention policy. This chapter, initially ambitious, has been pruned in each successive draft version, but benefited from a number of amendments during the parliamentary debate. In particular, it was suggested that obesity prevention should be a public health priority. There were proposals to ban advertising of high sugar/calorie products to children. But they were rejected by the Senate.

The major concrete measure is the restriction of alcohol and tobacco sale to young people (below the age of 18 years).

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

The major declared objectives of this reform are eminently sensible, namely:

• to reinforce regional governance;
• integrate the management of hospital, ambulatory and social care; and
• emphasize the importance of primary and coordinated care in the system.

However, the coherence between the objectives set and the structural measures proposed can be questioned. While the intention is to improve autonomy at the regional and hospital level, some argue that if anything the reform will reduce the autonomy of public hospitals which will be directed by centrally appointed directors who will be accountable to a board of management and to the State. The real power in the system is given to the directors of the ARS (nominated by the government as well) who will control the resources and define the strategy for hospitals in a region. Each hospital (including private ones) will have to sign a contract to define their activity and financing needs (contracts d'objectif et de moyen).

There is a risk of regional decisions presented by ARS to be moulded in Paris.

The sceptics note the impossibility of carrying out a regional policy by centrally appointed directors.

Nevertheless, this reform is a step forward in reducing the fragmentation between hospital, ambulatory and social care sectors, which has been a chronic problem of the French healthcare system. While it would be unrealistic to expect miracles overnight, we can hope for some improvements in care coordination and quality in the longer term.    

Purpose and process analysis

Current Process Stages

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

Initiators of idea/main actors

• Leistungserbringer

• Kostenträger

• Patienten, Verbraucher

Stakeholder positions

National/Regional health insurance funds:

The major issue which created a lot of conflict was the distribution of power between health insurance funds and new Regional Health Authorities (ARS). Until now the National and Regional Health insurance funds were the only interlocutor/actors in negotiating with physicians and defining the politics of care provision in the ambulatory sector. With the fear of losing ground and power, they did everything to limit the power given to ARS, but have not been successful.

Physicians:

Reactions by physicians have differed; those working in public hospitals and in the ambulatory sector have reacted with a rare vehemence to this law. There were many manifestations before and during the debate in parliament. Hospital physicians feared mainly that they will lose their managerial power in hospitals with new management rules and in a more competitive environment where they may lose their advantages. Ironically the physicians in private clinics and famous surgeons joined the movement when the amendment was voted for controlling extra fees for patients in private clinics. They have been successful in lobbying to remove this amendment.

Ambulatory care doctors on the other hand were of course fiercely against the idea of imposing limits to physicians' liberty of installation. 

Patient associations:

Initially supporting the law, patient associations were extremely disappointed by the modifications made under pressure by the medical profession. In particular concerning the chapter on access to care, patients/consumers are the losers of the legislative process. The major patient association has published an open letter to the parliamentarians ("letter to the parliamentarians who stopped representing us") deploring the refusal of several amendments:

• The refusal to take any official measures to detect and sanction doctors who refuse to treat patients with CMU coverage, 
• The refusal to control overbilling in private clinics,
• The refusal to introduce more strict measures to force ambulatory-care doctors to improve after hour care. 

Actors and positions

Leistungserbringer
Physicians in public hospitals	sehr unterstützend		stark dagegen
Ambulatory care physicians	sehr unterstützend		stark dagegen
Kostenträger
Public health insurance funds	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patient associations	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

The Parliament started to discuss the law at the beginning of February 2009. Despite an "accelerated" procedure, discussions of the draft law took more than six weeks(voted in parliament mid-March). This text was then discussed in different commissions of the Senate between May and June 2009. Seven measures in the final text voted in a plenary session of the Senate on June the 16th were taken to the Constitutional court by the socialist members of parliament.  

Objections were formulated against eight articles relating in particular to:

• The participation of private clinics in performing public service missions;
• the governance of public hospitals;
• the nomination of people outside the civil service as directors of ARS;
• the participation of private companies in providing therapeutic education programs;
• the changes to prescription procedures; and
• the way of personnel will be assigned to the future ARS.

All of these objections were rejected. The Council expressed only two reservations of interpretation. These concerned the articles setting up pilot measures, such as the recording of medical files on USB key or the proposition of a free preventive visit for young adults, without fixing their term.

Legislative outcome

Enactment

Actors and influence

Leistungserbringer
Physicians in public hospitals	sehr groß		kein
Ambulatory care physicians	sehr groß		kein
Kostenträger
Public health insurance funds	sehr groß		kein
Patienten, Verbraucher
Patient associations	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

The objective is to set up the ARS in the first quarter of 2010. The directors of these institutions were already appointed by the cabinet at the beginning of October.

Monitoring and evaluation

 

Expected outcome

 

Impact of this policy

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

 

References

Sources of Information

Final text of the projet law HPST: www.senat.fr/dossierleg/pjl08-290.html

Reform formerly reported in

Regional healthcare planning Process Stages: Umsetzung

New regional health governance Process Stages: Strategiepapier

Author/s and/or contributors to this survey

Zeynep Or

 

Empfohlene Zitierweise für diesen Online-Artikel:

Or, Zeynep. "Update on new regional health governance". Health Policy Monitor, Ontober 2009. Available at http://www.hpm.org/survey/fr/a14/2