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In January 2003, France's sickness insurance funds reached a deal with doctors' trade unions on issues such as consultation fees, insurance and healthcare 'best practice', paving the way for a formal agreement. However, talks on this latter agreement, which are scheduled to conclude by 31 March 2003, will run up against diverging interpretations among the parties on specific points of the January deal.
Negotiations on a new agreement governing the relationship between doctors in private practice and the sickness insurance funds were, in theory, scheduled to conclude by 31 December 2002. However, the social partners ended up walking away from the bargaining table in mid-December with an 'agreement to disagree'. The insurance funds, working within the framework of the 2003 spending envelope for health insurance passed by parliament, had been suggesting fee increases for doctors at a total estimated cost of EUR 150 million. The major doctors’ trade union costed its demands for fee increases at EUR 500 million. Negotiators had agreed to reconvene talks on 17 January and continue the bargaining process during February 2003.
At this point, the Minister of Health intervened to expedite negotiations. New talks were convened and concluded with an agreement on 10 January 2003.
Four out of the five doctors’ unions signed the new agreement, which defines 'the strategic framework for the overhaul of the relationship between doctors and the sickness insurance funds'. The signatory unions combined garnered 90% of votes cast in the most recent elections of doctors' representatives. Such broad union support for an agreement with the insurance funds has not been seen since the early 1970s.
Ambitious agreement
The scope of the agreement goes beyond mere fee-related issues. It also deals with changes to practices in the medical profession and puts forward priorities for public health. The main initiatives focus on fees, third-party insurance coverage for doctors as well as the implementation of new forms of remuneration and 'healthcare best practice agreements' (accords de bons usages des soins, AcBUS).
- On the issue of fees, three consultation-fee scales are to be created. The fee for a basic consultation with a specialist will increase from EUR 22.87 to EUR 23 from 1 February 2003. A new fee scale for an 'in-depth' consultation is to be established by 31 March 2003, with a proposed EUR 26 fee to rise to EUR 28 on 1 October should rises in volume allow. The exact nature of an in-depth consultation has yet to be made clear. Lastly, a third consultation-fee scale of EUR 40 is also envisaged. The definition of this type of consultation has also yet to be fleshed out.
- The agreement provides for an increase in the fixed fee general practitioners are paid for 'paediatric consultations' (compulsory examinations for young children) and for the creation of an 'in-depth' paediatric consultation fee of EUR 26.
- Insurance companies, using the drafting of patients’ rights legislation as a pretext, have opted for a sharp increase in the premia paid by practitioners for third-party insurance. The new agreement provides for two-thirds of insurance premia over EUR 1,000 to be picked up by sickness insurance funds in 2003. It also stipulates that collective insurance arrangements for all doctors covered by the new agreement will be created by March 2003, to apply from 2004.
- The new agreement provides for the implementation of new forms of remuneration designed to promote doctors' participation in public health contracts (contrats de santé publique) or to foster a more effective distribution of healthcare professionals throughout France.
- Lastly, the agreement calls for the drafting of 'healthcare best practice agreements' in all healthcare sectors by the end of 2003.
Like the June 2002 agreement (FR0206105F), which ushered in increases in general practitioners' consultation fees, the new agreement also contains a 'trade-off' component. Fees, mainly for medical consultations, are increased in exchange for commitments in the areas of consultation volume and changes in doctors’ practices. In June 2002, general practitioners made commitments on the prescription of (cheaper) generic drugs as well as on a reduction in the number of home visits. Data available at the end of 2002 do indeed show an increase in the prescription of generic drugs and a cut in the number of home visits. Commitments in the new January 2003 agreement focus on specialist consultation volume and the creation of healthcare best practice agreements.
Many components of agreement still require negotiation
Many outstanding issues will have to be negotiated by 31 March 2003 if the deal reached on 10 January is to be transformed into a formal agreement. These issues include: developing a specific definition for the various consultation-fee scales; fleshing out the public health contract initiative; establishing a negotiated definition for healthcare best practice agreements; and tackling the third-party insurance issue
However, the various parties’ diverging interpretations of the substance of the agreement suggest that the negotiation process will not be easy.
For the National Employed Workers' Sickness Insurance Fund (Caisse nationale d’assurance maladie des travailleurs salarié, CNAMTS), the agreement – introducing an element of flat-rate charging alongside consultation fees - should promote changes in the way doctors deliver care by fostering the creation of networks. CNAMTS also sees healthcare best practice agreements as a way of improving the quality of care.
However, the main doctors' union, the Confederation of French Doctors' Unions (Confédération des syndicats médicaux français, CSMF) sees 'this agreement as nothing more than the foundations and framework; the house still has to be built.' In the view of this union, which has always championed the consultation fee payment system, the new deal endorses 'a fee system based essentially on the consultation fee principle'. In late 2002, CSMF was calling for the creation of specific 'areas of fee freedom'- in other words, allowing doctors to charge fees other than those prescribed by the health insurance reimbursement system. CSMF signed the January 2003 agreement and now contends that healthcare best practice agreements provide the fee freedom it is seeking for physicians.
The actual substance of the formal agreement to be signed on 31 March 2003 will indicate which interpretation of the 10 January agreement has in fact prevailed.
Commentary
The previous Socialist-led government had passed legislation designed to reorganise the structure of agreements governing sickness/health insurance into three categories (FR0108159F) : a) overall agreements negotiated, not only with doctors, but with health professionals as a whole ; b) profession-specific agreements, with the possibility of separate deals for general practitioners and specialists; and c) the possibility of individual contracts between funds and healthcare professionals. It is this that has seen the development of flat-rate charging.
In mid-November 2002, doctors – notably the Confederation of French Doctors' Unions (CSMF) – prevented the implementation of an overall framework agreement, which was supported by the majority of the other representative healthcare unions. The January 2003 agreement, covering both general practitioners and specialists, was reached only with doctors. There are currently no individual contracts. Therefore, it is easy to see why CSMF describes the January deal as a 'political' agreement.
In the wake of the new deal, some medical specialists have begun to demand sometimes hefty surcharges from patients on the pretext that they are being treated more promptly. This does not bode well for a positive outcome to talks. (Pierre Volovitch, IRES)