Download article in original language : FR0206105FFR.DOC
Following a dispute which began in late 2001, on 5 June 2002, French sickness insurance funds and general practitioners' trade unions signed an agreement on consultation fees, increasing the basic fee from EUR 18.5 to EUR 20. The government had been pressing for such a deal. During the dispute, some doctors had engaged in forms of industrial action which directly challenged the very principle of the sickness insurance fund system. Some parties in the dispute believe that the June agreement opens the way for an overhaul of the relationship between the sickness insurance funds and healthcare professionals, while others view it as an 'armistice', which fails to address any of the substantive issues.
A major wave of industrial action by general practitioners began in November 2001, aimed at obtaining from the sickness insurance funds a major increase in the fees for consultations with patients (FR0201110F and FR0203105F). An agreement providing for an increase in consultation fees and the implementation of a more effective drug-prescription policy was finally signed on 5 June 2002 by three sickness insurance funds and three of the four doctors' trade unions. The sickness funds involved were the National Employed Workers' Sickness Insurance Fund (Caisse Nationale d'Assurance maladie des travailleurs salariés, CNAMTS) for employees, the Agriculture Welfare Mutual Society (Mutualité Sociale Agricole, MSA) for the agricultural sector and the National Independent Professions' Sickness Insurance Fund (Caisse Nationale d'Assurance maladie des Professions Indépendantes, CANAM) for self-employed shopkeepers and craftworkers. The unions involved were the French Federation of General Practitioners (Fédération Française des Médecins Généralistes, MG-France), the Confederation of French Doctors' Unions (Confédération des syndicats médicaux français, CSMF) and the Union of Liberal Doctors (Syndicat des Médecins Libéraux, SML).
Agreement
Under the agreement, consultation fees have increased significantly from EUR to 18.5 to EUR 20 as of 1 July 2002 and the fees for house calls will rise to EUR 30 on 1 October 2002. In return, savings will be generated through the increased prescription of International Non-proprietary Name (INN) drugs. Under this approach, drugs will be prescribed based on the active ingredients they contain and not on the brand name. This type of drug is to make up an average of 25% of all prescribed medication. In addition, generic drugs - where the patent has become public property – are to account for 50% of all non-over-the-counter medication. Under this agreement, physicians are also required to cut the amount of antibiotics they prescribe.
The CNAMTS board considers that this agreement will be self-funding. This is indeed possible, mathematically speaking. In reality, whether it is or not depends largely on the goodwill of the various parties involved - the impact of the increase in fees depends on the increase in the number of consultations. Estimates of the overall cost of the agreement vary from EUR 500 million to almost EUR 800 million, of which only part is covered by the sickness insurance funds, with the remainder being met by either patients themselves or by optional top-up insurance schemes. Consequently, while the overall cost of the 5 June agreement stands at EUR 500 million, the additional burden borne by the sickness insurance funds amounts only to EUR 380 million. It is estimated that the use of generic instead of brand-name drugs for the 20 most widely prescribed medications would save EUR 256 million. Systematically prescribing generic drugs where possible would lead to approximate savings of EUR 610 million. More effective prescription of antibiotics could generate savings of EUR 100 million.
All doctors' trade unions had called for consultation fees to be increased to EUR 20. There was disagreement however, over trade-off measures and tactics. MG France has always accepted the idea that fee increases should be dovetailed with a commitment by physicians to curb spending. However, the other doctors' unions had either expressed misgivings or outright hostility over the concept.
CSMF had called on physicians to refuse weekend on-call duty. Various radical-action 'coordinations' were set up. Some doctors opted unilaterally to set consultation fees at EUR 20. Later, some 'coordinations' attempted to launch a nationwide drive calling on doctors to sever all ties with the various sickness insurance funds. Through such tactics, physicians participating in 'coordinations' have challenged the very basis of the sickness insurance fund scheme. The French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT) - along with family, patient and consumer associations - was the only trade union organisation to campaign openly against this type of approach.
The 5 June agreement puts an end to all potential sanction procedures against doctors who charged unapproved fee rates.
The new conservative government led by Prime Minister Jean-Pierre Raffarin - which was appointed before the general elections on 9-16 June and reappointed thereafter - reasserted its resolve to increase consultation fees to EUR 20, while reiterating its desire to re-establish social dialogue and give the social partners their rightful place in the process, as well as its goal of cutting taxes and statutory social security contributions as a whole (FR0206102N). After some hesitation, the new Minister of Health confirmed that the issue of relations with health professionals was indeed the responsibility of the sickness insurance funds. Funding remains, however, a largely open issue. It goes without saying that this issue revolves around the ability of the new agreement to sustain itself in practice. It also depends on the action taken in relation to demands being made by other healthcare professionals. Lastly, it is tied to changes in the financial situation of the sickness insurance fund. A deficit of between EUR 4.5 billion and EUR 5 billion has been forecast for 2002.
Trade union reactions
In the opinion of the CFDT union confederation, the agreement of 5 June maintains the principle of refunding consultation fees from the social security system, avoids potential increases in sickness insurance contribution and stops patients having to bear part of the cost of the EUR 20 fee. CFDT also expressed its satisfaction at the commitment by general practitioners' trade unions to a more effective use of prescription drugs and to talks with the CNAMTS.
The General Confederation of Labour (Confédération générale du travail, CGT) had stated for some time that an EUR 20 fee was a legitimate demand. However, it lamented the fact that the debate was focused solely on one issue rather than on the whole range of problems facing the French health system. In the opinion of CGT, 'it would be quite inappropriate to expect social security beneficiaries to bear the burden of funding this initiative.' CGT believes that the basis of a new healthcare agreement must be developed through consultation with all the members of the CNAMTS board (FR0203105F).
In late May 2002, the General Confederation of Labour-Force ouvrière (Confédération générale du travail-Force ouvrière, CGT-FO) pointed to the exasperation felt by doctors and lamented the fact that the CNAMTS board continued to refuse to participate in overall negotiations. The union is doubtful that the 5 June agreement will be self-funding. Its health expert added that 'the substantive issues are far from being resolved.'.
The National Federation of Independent Unions (Union nationale des syndicats autonomes, UNSA) considers that 'ways of optimising sickness insurance resources must be found urgently', while the French Confederation of Professional and Managerial Staff-General Confederation of Professional and Managerial Staff (Confédération française de l'encadrement-Confédération générale des cadres, CFE-CGC) concluded that 'the agreement provides only ad hoc measures and fails to tackle the crux of the issue'.
The main organisation for mutual sickness insurers, the National Federation of French Mutual Insurers (Fédération nationale de la mutualité française, FNMF), which, in the light of its role as a top-up insurer, will feel the full brunt of the financial implications of the June agreement, stated that 'the only real certainty to emerge from the agreement is that the monthly income of doctors will increase by EUR 1,400 . […] In return, doctors have reiterated their ongoing and as-yet-unfulfilled pledge to use prescription drugs more effectively; [a promise] which is not backed up by any implementation guarantees.'
Commentary
A sizeable proportion of general practitioners have expressed a deep-rooted lack of understanding of, or even hostility towards, the sickness insurance fund system. It is interesting or even worrying to note that during the dispute, doctors did not hesitate to revive the rhetoric used by their predecessors in the 1930s to condemn the creation of insurance funds. Some French general practitioners have yet to take on board the idea that healthcare professionals' income in fact depends on the ability of sickness insurance funds to make adequate resources available to cover demand
The exasperation felt by doctors is linked to the 1995 Juppé social security reform programme, and also to the fact that the sickness insurance funds and the government have, for many years, opted to sign 'general practitioner care agreements' with minority trade unions.
Against this backdrop, the conclusion of the agreement of 5 June 2002 seems to be a necessary prerequisite to re-establishing dialogue. This agreement is far from opening the way to an overhaul of the role of general practitioners in the healthcare system. (Pierre Volovitch, IRES)