Improvement of the coordination in health care

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

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Abstract

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.

Purpose of health policy or idea

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:

1. The level of reimbursement of specialised care will be better if the patient is referred by a doctor whom he has chosen to be his usual doctor (le médecin traitant). This doctor may be a general practitioner or a specialist, whatever his practice setting is (hospital, health care centre, independent practice…). Patients who do not choose a usual doctor, or see another doctor without referral (except for paediatricians, ophthalmologists and gynaecologists), will have extra user charges: the coinsurance rate will be higher, and the specialist may charge extra fees.
2. By 2007 an electronic personal medical record (dossier médical personnel, DMP) will be introduced. It will include all visits, procedures, medical or surgical treatments, drugs and medical devices prescribed, etc. All professionals dealing with the patient will be able to access this data and complete it. Patients without DMP will have extra user charges.
3. From now on, exemptions of copayments for people with serious illnesses will be conditioned by the acceptance, by the patient, of a protocol of care agreed on by his usual doctor and the sickness fund doctor. The patient will have to show this protocol to all physicians visited in order to be fully reimbursed.

Main points

Main objectives

Improvement of the coordination of health care.

Type of incentives

Financial incentives through coinsurance and copayment.

Groups affected

Patients, Physicians (specialist and general practionner), Voluntary Health Insurers depending on theirs reimbursement policy

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

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.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

See above.

The usual doctor scheme may be viewed as an extension of the concept of referring doctor, but it is now compulsory.

Initiators of idea/main actors

• Government

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

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.

Actors and positions

Government
Government	very supportive		strongly opposed
Parliament	very supportive		strongly opposed
Payers	very supportive		strongly opposed

Actors and influence

Government
Government	very strong		none
Parliament	very strong		none
Payers	very strong		none

Positions and Influences at a glance

Monitoring and evaluation

There will be probably an evaluation process of the usual doctor scheme, led by the sickness funds.

Expected outcome

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.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable

References

Author/s and/or contributors to this survey

Dominique Polton and Julien Mousquès

Suggested citation for this online article

Dominique Polton and Julien Mousquès. "Improvement of the coordination in health care". Health Policy Monitor, October 2004. Available at http://www.hpm.org/survey/fr/a4/2