Preferred doctor reform

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

Abstract

The 2004 Health Insurance Reform modified the principles of care coordination in France by introducing in January 2005 a system of non compulsory coordinated care pathways for patients. It had three main features: introduction of a primary care doctor (preferred doctor scheme), initiation of capitation in ambulatory physician payment and reduction in patient’s freedom of choice through financial incentives.

Recent developments

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

Ultimately this reform is a first attempt to introduce some rationalization in the system through gate keeping. This long term objective cannot be evaluated yet. Currently, the reform has increased the level of complexity in the system through interlinked payment schemes.

In the short term its impact on the overall expenditure in ambulatory sector appears to be positive from the payer's point of view, but earlier experiences show that these short term effects, especially if they depend on physicians' good will to prescribe less, do not necessary stand in the middle to long term.

Purpose and process analysis

Current Process Stages

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

Initiators of idea/main actors

• Government

• Providers

• Patients, Consumers

• Political Parties

Stakeholder positions

Despite their initial support for the reforms, the unions of specialists put pressure on the government to obtain financial compensations in specialities that were particularly sensitive to the reform. This led, in March 2006, to an amendment of the agreement between physicians and the sickness fund. The sickness fund agreed to compensate the future financial loss of specialists in six specialities where the activity declined significantly: rehabilitative care, dermatology, endocrinology, rheumatology, otolaryngology and internal medicine.

In these specialties, the prices for certain procedures were increased. For example the consultation fee for specific coordination visits for diabetic patients increased by 10€. The total cost of these compensations is estimated to amount to around 32.4 million € a year. 

The reactions of generalists and specialists concerning the reform are not uniform. On both sides the reform was supported by some trade unions and rejected by others. Nevertheless the majority of physicians (generalists as well as specialists) are not very supportive of the reform. They think that the reform complicates care provision without really improving the current system. 

The pharmaceutical industry does not seem to have a firm position on the 'preferred doctor' scheme. But they clearly do not support the general agreement that was signed between the sickness fund and the physicians as part of the core reform in which there is a specific note on reducing drug prescriptions. 

Patients seem to have been compliant with the restrictions on access introduced by the reform. Eight over ten insured persons have signed a contract with a preferred physician so far (77% of insured adults in June 2006). Most of them think that the preferred doctor scheme is compulsory. 

The complementary insurance companies (mutuelles) which are expected to offer "responsible" contracts (see below) to their policy holders have been generally supportive towards the new gate-keeping scheme.

Actors and positions

Government
Government	very supportive		strongly opposed
Health insurance fund	very supportive		strongly opposed
Providers
Generalists	very supportive		strongly opposed
Specialists	very supportive		strongly opposed
Patients, Consumers
patients	very supportive		strongly opposed
Political Parties
UMP (center right)	very supportive		strongly opposed
Socialist party	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

The major agreement which was signed in January 2005 between physician unions and the Union of sickness funds was modified on March 23, 2006 (amendment n° 12) to provide financial compensations to the six selected specialities (impacted on negatively by the reform). The compensations are allocated in the form of a tariff raise for selected services. It is estimated that the total cost of these compensations would be about 32.4 million € a year.

Legislative outcome

Rejection of bill

Actors and influence

Government
Government	very strong		none
Health insurance fund	very strong		none
Providers
Generalists	very strong		none
Specialists	very strong		none
Patients, Consumers
patients	very strong		none
Political Parties
UMP (center right)	very strong		none
Socialist party	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

Complex payment and reimbursement scheme leads to implementation problems

Most of the implementation problems come from the fact that the proposed payment and reimbursement scheme is far too complex. Both health professionals and patients have difficulty in understanding how much is reimbursed (or not) in which situation.

Basically, if an individual chooses not to register with a preferred doctor, the rate of reimbursement he is entitled to from the health insurance fund is reduced from 70% to 60%. The same applies if a patient visits a GP other than his/her preferred doctor (except in an emergency) or if the patient consults a specialist without a referral. In any of these three situations, GPs and specialists in sector 1 are entitled to charge a supplemental fee, up to 17.5% of the official rate (note that 85% of GPs and 65% of specialists practice within sector 1 and charge fixed 'official fees', negotiated with the health insurance funds, in exchange for tax deductions. The remainder work in sector 2 and have always been allowed to charge supplemental fees). In the case of specialist consultations the maximum fee level on which reimbursement rates are based is also reduced. 

No reimbursement of financial penalties in case of non-compliance with preferred provider scheme

In order to make financial incentives effective, the reforms had to tackle the 'problem' of any offsetting effects from the comprehensive coverage against out of pocket payments offered by complementary insurance funds. In September 2005, the government requested that complementary insurers develop responsible contracts (contrats responsables), in which financial penalties due to non-compliance with the coordinated care pathway are not compensated under complementary insurance policies. In return, responsible contracts will benefit from tax deductions.

The physician does not receive any per capita payment for the follow-up of registered patients, except for those suffering from severe chronic diseases (including those with diabetes, severe hypertension, HIV etc), all of whom are exempt from co-payments. In this case, the attending physician receives an annual payment of €40 per registered patient for drafting a care protocol. 

Direct access to certain specialists

Direct access to gynaecologists, ophthalmologists, psychiatrists, neuro-psychiatrists and neurologists is permitted without penalty in certain circumstances (for instance, for contraception advice, cervical cancer screening, and the prescription of eye glasses). Also the coordinated care pathway does not apply to children under sixteen, so consultation with a paediatrician is not dependent upon a referral. 

Patients are allowed to change their preferred doctor at any time (and as often as they wish) by simply informing their health insurance fund. 

Nevertheless the sickness funds information system is not capable yet of tracing patient contacts with the system properly. An estimated 5% of reimbursed treatments are eventually classified as "out of pathway" because of errors in filling in the forms.

Monitoring and evaluation

Global evaluation of the reform is so far carried out in three dimensions:

• Impact on GPs' and specialists' activity. Between October 2005 and March 2006, the fee for service income of generalists has increased by 3% and that of specialists by 1.5% compared with the same period of the year before. At the same time, the number of GP visits has decreased by 1.2% while visits to specialists decreased somewhat less. Despite this stability in overall activity, the impact has been quite different for those specialities losing direct access. For the same period, the endocrinologists, dermatologists and rehabilitation care specialists reported a fall in their income ranging from 4.5% to 5.6%. But any efficiency gains arising from the substitution of GP contacts for specialist contacts would be partly offset by the adjustments made in March 2006 to compensate income losses of these specialists.
• Patients' compliance with the new system is followed quite closely by measuring the percentage of those signing a contract with a preferred doctor. In June 2006, 77% of the adult insured population had a preferred doctor and 93% knew about the preferred doctor scheme. But at the same time, generalists have already played a central role in primary care provision before the preferred doctor scheme was introduced, albeit in an implicit form. In 2002, eight out of every ten members of the public reported having a regular GP; this corresponds to the exact proportion of those having chosen a preferred doctor in 2006.
• Macro impact: evolution of total health expenditures. While the ultimate objective of the reform was to control and reduce total expenditure in ambulatory sector, it is very difficult to isolate the impact of the reform on expenditure as it occurred at the same time as a number of other changes in the system. The new per capita payment system might have a potential impact on public expenditures. The specific per capita payment for patients suffering from severe chronic illness may be an incentive for physicians to classify their patients in this category (with the additional effect of exempting them from co-payments for health care related to the declared chronic disease). If this happens, it may result in greater costs to the health insurance funds. This will be to the benefit of complementary insurers which generally have born the greatest share of these co-payments. However, if changes are justified by the health status of patients, they will lead to better access to care and a fairer distribution of costs between the basic and complementary health insurance funds. 

No monitoring has been undertaken so far of the impact of the reform on equity in access to care, patient satisfaction, or quality of care.

Expected outcome

See above.

Quality of care: The reform is expected to have a positive impact on quality of care as a result of better coordination of health care provision and the use of electronic patient records (if they are introduced). But for the moment there is no measurable evidence.

Equity: Substantial changes to both the monetary and non-monetary costs required to access specialist care services may have a negative impact on equity leading to inequalities in the use of such services between different socioeconomic groups.

Cost efficiency:  Short-term efficiency gains have been partly offset by concessions made to physicians and the potential for future savings remains to be seen.

References

Sources of Information

Haut Conseil pour l'avenir de l'assurance maladie. Rapport du Haut Conseil pour l'avenir de l'assurance maladie (High Council report on the future of health insurance). Paris: Ministère de la Sante et des Solidarities, 2004. Available on-line at www.securite-sociale.fr/actu/maladie/haut_conseil/rapport2006/hcaam_rapport2006.pdf 

Bras PL. Le médecin traitant: raisons et déraison d'une politique publique. (Regular Physicians: rationale and insanity of a public public policy) Droit Social 2006;1:59-72.(biblio n° 1626*) 

Laure Com-Ruelle, Paul Dourgnon, Valérie Paris Can physician gate-keeping and patient choice be reconciled in France ? Analysis of recent reform.. In « Eurohealth », 2006, vol.12, n° 1 pp. 17-19. (biblio n° 1626*) Available on-line at www.lse.ac.uk/collections/LSEHealthAndSocialCare/pdf/eurohealth/vol12no1.pdf

Reform formerly reported in

Provider-Payer Contractual Reorganization Process Stages: Pilot

Author/s and/or contributors to this survey

Paul Dourgnon

Personal page: www.irdes.fr/irdes/equipe/dourgnon.htm

Suggested citation for this online article

Paul Dourgnon. "Preferred doctor reform". Health Policy Monitor, October 2006. Available at http://www.hpm.org/survey/fr/a8/2